The ASSESSMENT

1
The ASSESSMENT
2
What is the assessment?

• An ASSESSMENT is the gathering of relevant
  information about the client, their environment,
  their problem(s), and what they hope to
  accomplish through the therapeutic intervention.

3
What are the goals of the Assessment?

• The assessment should enable both the client and
  Clinician to answer the following questions
• Is treatment of any kind required?
• If treatment is indicated, what are the relative
  merits of the intervention?
• What types of treatment approaches might be
  appropriate?
• What is the depth of therapy needed?
• Who should the therapy involve?
• Have cultural issues been considered?

4
The Assessment should answer these basic
questions.

• For what problems is the client seeking
  treatment?
• How have these problems affected the clients
  life?
• What is maintaining these problems?
• What does the client hope to gain from treatment?

5
Who can conduct an Assessment?

• Assessments should be conducted by qualified
  personnel who
• Licensed Counselor (LCDC, LPC, LMSW, Ph.D)
• Registered Counselor Intern
• Is knowledge to assess the specific needs of the
  client being served
• Are trained in the use of applicable and
  appropriate tools and,
• Are culturally sensitive to the clients needs.

6
What should the Assessment include?

• Presenting Problem or Chief Complaint
• Alcohol and Other Drug Use History (use)
• Family and Social/Leisure History (activities)
• Educational/Employment History (training)
• Legal History
• Mental Health History (mental/emotional
  functioning)
• Medical History (HIV, STD, TB, HEP)
• Client Strengths and Limitations
• Recommendations

7
Presenting Problem

• Answers the questions
• What brings you here today?
• Why do you think you need treatment?
• The answers provide immediate insight into what
  the client considers the most pressing problem
  and provides clues as to how distressing these
  problems are.
• If the client is entering treatment voluntarily,
  information relating to how motivated the client
  is for treatment, and their expectations for
  treatment can also be obtained.
• client responses to these questions should be
  recorded verbatim.

8
History of the Problem

• Thorough knowledge and understanding of the
  problems history can greatly facilitate its
  treatment.
• Your documentation should include the following
• When the client began experiencing the problem,
• Their perception of the cause of the problem,
• Significant events that occurred at or the time
  the problem began
• Precipitants of the problem,
• What maintains the problems presence,
• The problems course over time,
• How the problem effects the clients ability to
  function,
• What the client has done to try to deal with the
  problem.

9
Alcohol and Drug Use

• Substances used in the past, including prescribed
  drugs. Substances used recently, especially
  those used within the last 48 hours.
• Frequency of use, amount of use, duration of use
  and route of administration.
• Substances of preference.
• Previous occurrences of overdose, withdrawal, or
  adverse drug or alcohol reactions.
• History of previous substance abuse treatment
  received.
• Year or Age of first use of each substance.

10
Family, Social Leisure

• Helps you understand how the client got to this
  point through a familial context.
• Important aspects of the family history include
• The occupation and education of patents,
• The number of siblings and their birth order,
• The quality of clients relationship to parents
  and or siblings
• Significant extended family members,
• Parental approach to child rearing,
• Familial expectations for the client.

11
Family, Social Leisure

• Helps you understand how the client got to this
  point through a social context. It may also
  provide you with information relating to the
  clients ability to relate well with and take
  directions from perceived authority figures.
• Important information includes
• the general number of and types of friendships
  participation in team sports involvement in
  clubs or other social activities being a leader
  vs. a follower involvement in religion,
  political or gang activities, and other
  opportunities requiring interpersonal
  interactions.
• The clients experiences stemming from being a
  member of a racial or ethnic minority, which can
  have a significant bearing on their current
  problem and coping styles.

12
Educational

• This generally provides limited yet potentially
  important information. The attained level of
  education can give you an rough estimate of the
  clients level of intelligence. It also speaks
  to the clients aspirations, goals, ability to
  gain from learning experiences, their willingness
  to make a commitment, their amount of
  perseverance, and their ability to delay
  gratification.

13
Employment

• This can provide you with a wealth of information
  that can be useful in understanding the client
  and developing an effective treatment plan.
• Interactions with supervisors and peers can
  provide you with insights into the clients
  ability to get along with others and take
  direction.
• In addition, the clients ability to assume and
  meet the expectations of being a hired employee
  may have implications for assuming the role of a
  client and complying with treatment
  recommendations.

14
Legal History
15
Mental Health History

• A previous history of behavioral health problems
  and treatment is important to know. This should
  be documented regardless of the level of care.
• Obtaining this information can shed light on
  whether the current problem is part of a single
  or recurrent episode, or a progression of
  behavioral health problems over a period of time,
  what treatment approaches have or have not worked
  in the past, and the clients willingness to
  engage in the treatment process.
• Important to get an idea of current emotional
  functioning, especially with youth.

16
Substance Abuse History Questions to Ask clients

• Inquiry into patterns of substance use should
  include the following
• Substances used in the past, including prescribed
  drugs.
• Substances used recently, especially those used
  within the last 48 hours.
• Substances of preference.
• Frequency with which each substance is used.
• Previous occurrences of overdose, withdrawal, or
  adverse drug or alcohol reactions.
• History of previous substance abuse treatment
  received.
• Year or Age of first use of each substance.

17
Medical History

• At a minimum, you should document any significant
  illnesses, hospitalizations, past and current
  physical illnesses or conditions (i.e., breast or
  prostate cancer, diabetes, hypertension),
  injuries or disorders affecting the central
  nervous system, any functional limitations.
• This information can provide clues to the
  presenting symptomatology, functioning, and
  suggest the need for referral to a psychiatrist
  or other medical professional for evaluation,
  treatment, and or management.
• You should include a cursory family history of
  significant medical problems.

18
client Strengths

• It is important to recognize that the benefits of
  assessing client strengths go beyond their value
  to the development of the treatment plan. They
  force clients to consider that their
  psychological assets can have therapeutic
  value(s) in themselves.
• In essence, strength-based assessments can serve
  as an intervention before formal treatment
  actually begins.
• They can help build self-esteem and
  self-confidence, reinforce the clients efforts
  to seek help, and increase their motivation to
  return to engage in the work of treatment.

19
Pain Assessment

• Each clinician should explore the existence and,
  if so, the nature and intensity of any pain
  experienced
• The results of the inquiry should be documented
  in a way that facilitates regular reassessment
  and follow-up
• There should be documentation of
• Education to the client and their families about
  effective pain management and
• Address client needs for symptom management in
  the discharge planning process.

20
Important client Characteristics

• It should be obvious that the assessment for the
  purpose of treatment planning should go beyond
  the identification and description of the
  clients symptoms or problems. The clients
  family, social, psychiatric, medical,
  educational, legal, and employment histories
  provide a wealth of information for understanding
  the origin, development, and maintenance of their
  behavioral health problem(s). At the same time,
  other types of information can be quite useful in
  developing a treatment plan.

21
Important client CharacteristicsFunctional
Impairment

• The degree to which behavioral health clients are
  impaired in their social, environmental and
  interpersonal functioning has been identified a
  one of the most important factors to consider
  during an assessment.
• Not only is social functioning information
  important for treatment planning and outcomes
  assessment, it is also critical for arriving at
  the Global Assessment of Functioning (GAF) rating
  for Axis V.

22
Clinical Indicators of Functional Impairment

• These impairments can be exhibited or reported
  during the assessment
• Problem interferes with the clients functioning
  during the assessment.
• client cannot concentrate on interview tasks.
• client is distracted even by minor events.
• client appears incapacitated by the problem and
  has difficulty in functioning.
• client has difficulty in interacting with the
  interviewer as a result of problem severity.
• Multiple areas of performance are impaired in
  daily life.

23
Important client Characteristics Subjective
Distress

• Subjective distress essentially refers to the
  state phenomenon however, an assessment of the
  clients trait level of distress may also yield
  information important to the treatment planning
  process.

24
Clinical Indicators of Subjective Distress

• The following high distress indicators may be
  exhibited or reported during the assessment
• High emotional arousal
• High symptomatic distress
• Motor agitation
• Difficulty in maintaining concentration
• Unsteady, faltering voice
• Autonomic symptoms
• Hyper-vigilance
• Excited affect
• Intense feelings

25
Clinical Indicators of Subjective Distress

• The following low distress indicators may be
  exhibited or reported during the assessment
• Decreased emotional arousal
• Decreased symptomatic distress
• Reduced motor activity
• Decreased investment in treatment
• Low energy level
• Blunted or constricted affect
• Un-modulated verbalization
• Slow verbalizations

26
Important client Characteristics Problem
Complexity

• Whether the clients presenting problems are high
  or low with respect to complexity can have an
  important bearing on the treatment planning
  process. Ascertaining the level of problem
  complexity can be facilitated by historical
  information about other aspects of the clients
  life. The historical information can allow for
  the revelation of recurrent patterns or themes
  arising within objectively different but
  symbolically related relationships.

27
Clinical Indicators of Problem Complexities
Non-Complex Problems

• The following may be exhibited or reported during
  the assessment
• Chronic habits and or transient responses
• Behavior repetition is maintained by inadequate
  knowledge or by ongoing situational rewards
• Behaviors have a direct relationship to
  initiating events
• Behaviors are situation specific

(Patrick, 32)
28
Clinical Indicators of Problem Complexities
Complex Problems

• The following may be exhibited or reported during
  the assessment
• Behaviors are repeated as themes across unrelated
  or dissimilar situations
• Behaviors are ritualized (yet self-defeating)
  attempts to resolve dynamic or interpersonal
  conflicts
• Current conflicts are expressions of the clients
  past rather than present relationships
• Repetitive behaviors results in suffering rather
  than gratification
• Symptoms have a symbolic relationship to
  initiating events
• Problems are enduring, repetitive and symbolic
  manifestations of characterological conflicts

(Patrick, 32)
29
Important client CharacteristicsReadiness to
Change

• The importance of the clients readiness to
  change in the therapeutic process comes from the
  work of Prochaska, DiClemente and their
  colleagues.
• They have identified five stages through which
  individuals go when changing various aspects of
  their lives. These changes apply not only to
  change that is sought by behavioral health
  treatment, but also in non-therapeutic contexts.
• The five stages are Pre-Contemplative,
  Contemplative, Preparation, Action and
  Maintenance.

(Patrick, 31)
30
Prochaskas Stages of ChangePre-contemplative

• Little or no awareness of problems, little or no
  serious consideration or intent to change, often
  presents for treatment at the request of or
  pressure from another party, change may be
  exhibited when pressure is applied but the client
  reverts to previous behavior(s) when pressure is
  removed. Resistant to recognizing or changing
  the problem is the hallmark of the
  pre-contemplative stage.

(Patrick, 33)
31
Prochaskas Stages of ChangeContemplative

• Awareness of problem and serious thoughts about
  working on it, but no commitment to begin to work
  on it, weighing pros and cons of the problem and
  its solution. Serious consideration of problem
  resolution is the hallmark of the contemplation
  stage.

(Patrick, 33)
32
Prochaskas Stages of ChangePreparation

• Intention to take serious, effective action in
  the near future (e.g., within a month) but has
  already made small behavioral changes. Decision
  making is the hallmark of this stage.

(Patrick, 33)
33
Prochaskas Stages of ChangeAction

• Overt modification of behavior, experiences or
  environment in an effort to overcome the problem.
  Modification of problem behavior to an
  acceptable criterion and serious efforts to
  change are the hallmarks of this stage.

(Patrick, 33)
34
Prochaskas Stages of ChangeMaintenance

• Continuation of change to prevent relapse and
  consolidate the gains made during the action
  stage. Stabilizing behavior change and avoiding
  relapse are the hallmarks of this stage.

(Patrick, 33)
35
Important client CharacteristicsPotential
Resistance to Therapeutic Influences

• The potential resistance to therapeutic
  influences may be an indicator of the clients
  motivation to engage in treatment.
• Two different types of resistance exists
• Resistance, which may be considered a state-like
  quality in which clients fail to comply with
  external recommendations or directions
• Reactance, a more extreme trait-like form of
  resistance that stems from the clients feelings
  that their freedom or sense of control is being
  challenged by outside forces. This is manifested
  as active opposition.

(Patrick, 32-33)
36
Important client Characteristics Social
Supports

• Documentation of social supports the clients
  perception of potential sources of psychological
  and physical support that they can draw upon
  during and after treatment.
• Should be examined from both the objective and
  subjective perspectives.

(Patrick, 33-34)
37
Social Supports Objective Perspective

• Objective social supports can be assessed from
  external evidence of resources available to the
  client, such as marriage, physical proximity to
  relatives, network of identified friends,
  membership in organizations and involvement in
  religious activities.

(Patrick, 34)
38
Social Supports Subjective Perspective

• Subjective social supports refers to the reported
  quality of the clients social relationships.

(Patrick, 34)
39
Important client Characteristics Coping Styles

• An important consideration for treatment planning
  is the identification of the clients coping
  style.
• Coping style is defined as an enduring trait
  that relates to the way one copes with personal
  or interpersonal threats.
• There are two identified coping styles
  internalization and externalization.

(Patrick, 34-35)
40
Coping Style Internalization

• This style of coping is suggested in clients who
  tend to
• Avoid, deny, repress or compartmentalize sources
  of anxiety
• Be overly introverted, introspective,
  self-critical, and self-controlled
• Be emotionally constricted.

(Patrick, 35)
41
Coping Style Internalization Clinical Indicators

• Denial
• Reversal
• Reaction formation
• Repression
• Minimization
• Unrecognized wishes or desires
• Introversion
• Social withdrawal
• Somatization (autonomic nervous system symptoms)

• Undoing
• Self-punishment
• Intellectualization
• Isolation of affect
• Emotional over-control or constriction
• Low tolerance for feelings or sensations
• High resistance for feelings or sensations

(Patrick, 36)
42
Coping Style Externalization

• This style of coping is suggested in clients who
  tend to
• Directly avoid, rationalize, project or act-out
  onto their environment(s)
• Exhibit a degree of insensitivity to their own
  and others feelings
• Be spontaneous, impulsive, extraverted, and
  sometimes manipulative.

(Patrick, 35)
43
Coping Style Externalization Clinical Indicators

• Ambivalence
• Acting Out
• Blaming others and self
• Low tolerance for frustration
• Difficulty in differentiating emotions
• Avoidance or escape (or both)
• Projection

• Conversation symptoms
• Paranoid reactions
• Unsocialized aggression
• Manipulation of others
• Ego-syntonic behaviors
• Extraversion
• Somatization (seeking of secondary gain via
  physical symptoms)

(Patrick, 36)
44
Mental Status Examination

• Any clinical assessment should include a mental
  status examination (MSE).
• This information comes from the clinicians
  observations of and impressions formed during the
  course of the clinical interview and as a result
  of other assessment procedures.
• Some aspects of the MSE usually require specific
  questioning that typically would not be included
  during the other parts of the assessment.
• The MSE generally addresses a number of general
  categories or aspects of the clients
  functioning, including descriptions of their
  appearance and behavior, mood and affect,
  perception, thought processes, orientation,
  memory, judgment, and insight.

(Patrick, 37)
45
MSE Outline

• Appearance (level of arousal, attentiveness, age,
  position, posture, attire, grooming, eye contact,
  physical characteristics, facial expression)
• Activity (movement, tremor, choreoathetoid
  movements, dystonias, automatic movements, tics,
  mannerisms, compulsions, other motor
  abnormalities or expressions)
• Attitude toward to clinician
• Mood (euthymic, angry, euphoric, apathetic,
  dysphoric, apprehensive)
• Affect (appropriateness, intensity, mobility,
  range, reactivity)
• Speech and Language (fluency, repetition,
  comprehension, naming, writing, reading, prosody,
  quality of speech)
• Thought Process (circumstantiability, flight of
  ideas, loose association, tangentiality, clang
  associations, echolalia, neologims,
  perserveration, though blocking)

(Patrick, 38)
46
MSE Outline

• Thought Content (delusion, homicidal or suicidal
  ideation, magical thinking, obsession,
  rumination, preoccupation, overvalued idea,
  paranoia, phobia, poverty of speech,
  suspiciousness)
• Perception (autoscopy, déjà vu,
  depersonalization, hallucination, illusion,
  jamais vu)
• Cognition (orientation, attention, concentration,
  immediate recall, short-term memory, long-term
  memory, constructional ability, abstraction,
  conceptualization)
• Insight
• Judgment
• Defense Mechanisms (altruism, humor,
  suppression, repression, displacement,
  dissociation, reaction formation,
  intellectualization, splitting, externalization,
  projection, acting out, denial, distortion)

(Patrick, 38)
47
Risk of Harm to Self or Others

• Assessment of suicidal or homicidal ideation and
  potential should always be assessed, even if it
  consists of no more than asking the question
  Have you been having thoughts of harming
  yourself or others?
• If the client answers yes, you should inquire
  further, asking about how long the client has
  been having these thoughts, how frequently do
  they occur, previous and or current plans or
  attempts, and opportunities to act on these
  thoughts.
• The presence of any given risk factor should
  always be considered in light of all available
  information about the client.

(Patrick, 39)
48
Examples of Commonly Identified Suicide Risk
Factors

• Male
• Caucasian
• Over 45 years old
• Unmarried
• History of previous suicide attempt
• Presence of a mental disorder, especially an
  affective disorder
• Current state of distress
• Poor impulse control
• Co-morbid physical problems
• Recent job, financial, or other loss
• Clues given at admission to suicidal ideation,
  intent or plan

(Patrick, 40)
49
Examples of Commonly Identified Homicide Risk
Factors

• Alcohol and readily accessible firearms are major
  factors in homicides. Other factors such as drug
  use, poverty or unemployment, racial
  discrimination, cultural attitudes, belief in
  male dominance, and even poor communication and
  problem-solving skills can also put persons at
  higher risk of being a homicide victim or
  offender.

50
Diagnosis and Related Considerations

• An accurate diagnosis can have important
  implications in the development of an effective
  course of treatment.
• Identification of a personality disorder on Axis
  II with or without an accompanying Axis I
  disorder would have a bearing on the projected
  length of treatment.
• Diagnoses are efficient tools for communicating
  among professionals and organizations.

(Patrick, 42)
51
DSM-IV Multi-axial Diagnostic System

• Axis I (Clinical Disorders, other conditions that
  may be a focus of attention) Examples
  Substance abuse, substance dependence, anxiety
  disorders, mood disorders, schizophrenia
• Axis II (Personality disorders, mental
  retardation) Examples Borderline personality
  disorder, antisocial personality disorder,
  avoidant personality disorder, mental retardation
• Axis III (General medical conditions) Examples
  Cancer, Hypertension, Diabetes, Migraines,
  Chronic Pain, Injuries
• Axis IV (Psychosocial and environmental
  problems) Examples Problems with primary
  support group, occupational problems, problems
  relating to social environment
• Axis V (Global assessment of functioning)
  Example GAF Score

52
Treatment Goals

• No assessment would be complete without the
  identification of treatment goals. In some
  cases, one or two goals might be identified, in
  others, several goals might be identified and
  prioritized by the importance and immediacy of
  the goal.
• Goals can be client-identified or third-party
  goals.
• To assist in clarifying and setting goals, it is
  important to have clients identify what the
  anticipated or hoped-for results of achieving
  their goals will be.

(Patrick, 42)
53
Treatment Goalsclient-Identified Goals

• In most cases, these are the most obvious goals.
  It was the amelioration of the unwanted behavior
  or other symptoms that led the client to seek
  treatment, which is their goal.
• Directly ask the client directly what their goals
  are using these three questions
• What do you see as our biggest problem?
• What do you want to be different about your life
  at the end of your treatment?
• Does this goal involve changing things about
  yourself?

(Patrick, 42-43)
54
client Identified Goals Does this goal involve
changing things about yourself?

• By asking the above question, it forces the
  client to think through their problems and
  realize the extent to which these problems have
  control over their thoughts, feelings, and
  behavior(s). It can provide a means for clients
  to gain insight into their problems a
  therapeutic goal in and of itself.

(Patrick, 43)
55
Client-Identified Goals

• It is suggested that clinicians ask clients the
  following questions relating to establishing
  objective outcome criteria for goal achievement
• How will you know when things are different?
• What kinds of things will you be doing
  differently?
• What negative things will no longer be present?
• What positive things will you be doing?
• These questions offer clients an opportunity to
  gain insight into their problems.
• Through clinician feedback clients can be helped
  to see how realistic their expectations are for
  treatment and determine whether those
  expectations should be modified.

(Patrick, 44)
56
Treatment GoalsThird Party Goals

• Treatment goals set by non-client stakeholders in
  the treatment process must always be considered.
  These stakeholders can be spouses, the judicial
  system, the employer, or other family members.
• As with client-identified goals, the third
  parties expectations for the outcomes of goal
  achievement should be sought, and they may also
  be modified based on the clinicians evaluation
  of how realistic they are.

(Patrick, 44)
57
Motivation to Change

• An important factor to assess for treatment
  planning is the clients motivation to change.
• How to arrive at a good estimate of the clients
  level of motivation to change
• Is the client seeking treatment from their own
  desire for help or from the request/demand of
  another?
• What is the clients stated willingness to be
  actively involved in the treatment process?
• What is the clients subjective distress and
  reactance?
• What is the clients readiness for, or stage of
  change?

(Patrick, 45)
58
Motivation to Change

• Seven factors have been identified that should be
  considered in the evaluation of motivation to
  engage in treatment
• A willingness to participate in the diagnostic
  evaluation.
• Honesty in reporting about oneself and ones
  difficulties.
• Ability to recognize that the symptoms
  experienced are psychological in nature.
• Introspectiveness and curiosity about ones own
  behavior and motives.
• Openness to new ideas, with a willingness to
  consider different attitudes.
• Realistic expectations for the results of
  treatment.
• Willingness to make a reasonable sacrifice in
  order to achieve a successful outcome.

(Patrick, 45)
59
Cultural Issues

• A critical component of the assessment is the
  addressing of cultural needs. Using culturally
  appropriate interventions can lead to better
  outcomes for clients.
• A simple working definition of the concept of
  culture is that it is a shared set of beliefs,
  norms, and values in which language is a key
  factor. Other factors that play an important
  role include ethnicity, race, sexual orientation,
  disability, and other self-defined
  characteristics.

(Adams, 68)
60
Cultural Issues

• It is important to remember that culture is not
  fixed or frozen in time, but rather exists in a
  constant state of change that is learned, taught,
  and reproduced. A framework for considering
  human diversity can be thought of using the
  ADDRESSING pneumonic, and includes the following
  factors

(Adams, 68)
61
Cultural Issues

• Age and generational influences
• Developmental and acquired Disabilities
• Religion and spiritual orientation
• Ethnicity
• Socioeconomic status
• Sexual Orientation
• Indigenous heritage
• National origin
• Gender

(Adams, 68)
62
Cultural Issues

• Issues of culture, ethnicity, race, and other
  attributes which individuals use to self-identify
  impact the quality of interactions with providers
  and thus the assessment. Cultural tradition,
  experience and bias, both by the client as well
  as the therapist, are all part of an unstated but
  powerful dynamic in the helping relationship that
  impacts how information is provided and received.
  

(Adams, 68)
63
Cultural Issues

• The assessment must consider how culture and
  social contexts shape the clients symptoms,
  presentation, and meaning, as well as coping
  styles, family influences, attitudes towards
  help, and a willingness to trust helping
  professionals are all influenced by the clients
  culture. The relationship between the therapist,
  the client, and their family are potentially
  shaped by differences in culture and social
  status.
• Your efforts at assessing the clients needs are
  impacted by factors including styles of
  communication, capacity for rapport, comfort with
  disclosure, the perception of safety and privacy,
  and the experience of power, dignity, and
  respect, all of which, to a degree, are
  culturally determined.

(Adams, 69)
64
Cultural Issues

• The impact of a number of other cultural issues,
  such as acculturation and immigration stress,
  identity, racism, marginalization, or
  discrimination, all affect help-seeking and
  successful engagement and must be considered.
  Issues of assimilation, alienation, and
  co-occurring trauma can also affect the
  experience of seeking and receiving treatment.

(Adams, 69)
65
Screening for Cigarette and Over-the-Counter
Medications

• When assessing the clients use of illegal
  substances, the client should also be questioned
  regarding their use of cigarettes and other
  over-the-counter medications that may have an
  effect on the client.

66
Housing Needs

• An important element in the treatment and
  assessment process is the determination of the
  clients current housing situation and housing
  needs. This may be one of the primary barriers
  to treatment, especially if the client is
  homeless or living in unsafe or unsanitary
  conditions.

67
Legal Status

• Another barrier to treatment is the clients
  involvement in the legal system. This
  involvement could hinder participation in
  residential treatment programs, especially if the
  client must leave the program for court or other
  legal related appointments. Additionally, there
  may be specific treatment requirements imposed by
  the legal system.

68
Known Allergies and or Sensitivities to
Pharmaceuticals

• It is important to know if your client has any
  allergies or sensitivities, document this
  information, and update it as appropriate. If
  there are no known allergies or sensitivities,
  NKDA should be documented to indicate no known
  drug allergies.

69
The Name and Amount of any Prescribed Medications

• It is important to the assessment and the
  treatment process to know what types of
  medications your clients may be taking. These
  medications could have side effects that affect
  their mood or affect. In addition, these
  medications may be counter-indicated for
  medications that may be prescribed by your
  agency. This information should be updated as
  appropriate.

70
Assessment Summary

• The goal of developing a useful and effective
  treatment plan can be achieved only through a
  good assessment.
• The manner and form of the assessment will vary
  for clinician to clinician, and from clinic to
  clinic.
• The focal areas or content of the assessment
  include the nature and history of the clients
  presenting problem, as well as other historical
  information important to understanding the
  problems development, maintenance, and effects
  on the clients current functioning. This
  includes the clients medical and behavioral
  health history.

(Patrick, 51)
71
Assessment Summary

• Information regarding the other client
  characteristics is also important to know for
  creating the treatment plan.
• The clients strengths or assets can be used to
  effect change, to motive them to engage in the
  therapeutic relationship, and to work to effect
  change(s) in their lives.
• Information obtained from the MSE and assessment
  of the clients risk or harm to self or others
  can assist in determining various aspects of
  care, including the appropriate level of care.

(Patrick, 51)
72
Assessment Summary

• The results of the MSE can also be used to assign
  a diagnosis to the client.
• No assessment would be complete without the
  therapist and client knowing the desired goals of
  treatment.

(Patrick, 52)
73
Assessment Summary

• Providing an emotionally safe environment for
  disclosure and to allay the fears, anxieties, and
  preconceptions of those seeking help is critical
  to success in assessment.
• Knowledge about other cultures, awareness of
  ones own limits, and willingness to seek help
  and consultation when necessary are also key
  ingredients for success.

(Adams, 68-69)
74
The Treatment Plan
75
What is the purpose of Treatment Planning?

• To clarify the treatment focus
• The set realistic expectations
• To establish a standard for measuring treatment
  progress
• The facilitate communication among professions
  (both Clinical and Support)
• To support treatment authorizations
• To document quality assurance efforts

(Patrick, 124)
76
How does the Treatment Plan clarify the focus of
treatment?

• The treatment plan must specify what and how the
  treatment will be working to accomplish.
• Initially, it is a tool to ensure that both the
  Therapist and client agree to the goals they are
  working towards and how they will get there.
• Throughout treatment, it serves as a reference
  that both parties can consult in order to verify
  that treatment is on tract relative to the
  established goals and objectives.

(Patrick, 3)
77
How does the Treatment Plan set realistic
expectations for treatment?

• It plan helps the client understand what they
  can realistically expect to occur during the
  course of treatment and at the end of treatment.
• It helps clarify the clinician and clients role
  in treatment.
• It sets the ground rules for therapy.
• It helps establish achievable goals before
  therapy begins to help minimize the changes that
  the client will be disappointed either during or
  at the end of the therapeutic experience.

(Patrick, 4)
78
How does the treating clinician use the written
treatment plan?

• The clinician should be considered the primary
  audience for this document.
• This document is something that the clinician
  should refer to regularly in order to ensure that
  the clients treatment is on track.
• It is a tool for the clinician to facilitate the
  process of therapeutic interventions.
• The treatment plan should be developed in a way
  that organizes the clinicians understanding of
  the client and their therapeutic needs.

(Patrick, 125)
79
How does the client use the written treatment
plan?

• This document should be developed and shared with
  the client.
• The client needs to agree with the identified
  problems, treatment goals, and the interventions
  indicated in the plan prior to the initiation of
  treatment.
• The clients buy-in is critical to achieving
  the stated goals of treatment.
• This document serves as a contract between the
  clinician and the client, something that the
  client can refer to when questions about the who,
  what, when, and why of some aspect of the
  therapeutic process arises during the course of
  treatment.
• It can be a source of reassurance to the client.
• It can serve as a means of holding both the
  clinician and client accountable for the roles
  and responsibilities they had mutually agreed
  upon prior to the initiation to treatment.

(Patrick, 125-126)
80
What are the purposes of the Treatment Plan?

• Clarification of treatment focus
• Provision of a standard against which to judge
  treatment progress
• Clarification of realistic treatment expectations
  for the client
• Facilitates communication with the clients other
  care providers
• Facilitates communication with external reviewers
  / payers
• Provides a record for quality assurance purposes

(Patrick, 3)
81
How does the Treatment Plan establish a standard
for measuring treatment progress?

• It is difficult to determine how much progress is
  being made during treatment unless you first know
  what the clients status was at the beginning of
  treatment and the expected outcome of treatment.
• It provides the criteria for terminating an
  episode of care.

(Patrick, 4)
82
What are the benefits of the treatment planning
process to Clinicians?

• Provides a road map to guide treatment
• Forces critical thinking in formulating
  interventions
• Helps meet payer requirements for accountability
• Assists in coordinating care with other
  professions (i.e., Psychiatrists, Physicians,
  Case Managers, etc)
• Provides protection from certain types of
  litigation

(Patrick, 8)
83
What are the benefits of treatment planning to
the client?

• It specifies what the focus of the treatment will
  be and what outcomes the client and the clinician
  will be collaboratively working toward.
• By encouraging the client to voice their
  treatment preferences, the therapist not only
  promotes the clients sense of autonomy and
  self-esteem, but cements the formation of a
  therapeutic alliance, and learns what treatment
  the client will be mostly likely to acceptand
  benefit from.

(Patrick, 8)
84
Why explore clients expectations for treatment?

• Most clients come to treatment with some
  expectations. These expectations include, but
  are not limited to what will be required of the
  client, what will be the responsibility of the
  clinician, the likely outcome, and the time it
  will take to achieve the desired goals.
• Knowing and understanding these expectations can
  have a significant bearing on the various types
  and aspects of treatment that you may propose to
  the client.
• It is important to understand these expectations
  to facilitate the client-clinician alliance.

(Patrick, 128)
85
What is informed consent for treatment?

• As part of the informed consent process,
  clinicians must make sure that clients understand
  what the treatment can be reasonably expected to
  accomplish and in what period of time, what any
  negative effects of the treatment might be, what
  other treatments might be considered, and whether
  these would be expected to be more or less
  helpful and or more or less costly.
• The failure to obtained informed consent could
  result in disastrous financial and professional
  consequences for the clinician.
• Additionally, beginning treatment without
  informed consent runs contrary to professional
  ethics.

(Patrick, 128-129)
86
Ethical Standards for Informed Consent for
Treatment

• Clinicians must obtain appropriate informed
  consent to therapy or related procedures, using
  language that is reasonably understandable to the
  participant. The content of informed consent
  will vary depending on may circumstances
  however, informed consent generally implies that
  the person (a) has the capacity to consent, (b)
  has been informed of significant information
  concerning the procedure, (c) has freely and
  without undue influence expressed consent, and
  (d) consent has been appropriately documented.
• When persons are legally incapable of giving
  informed consent, therapists obtain informed
  permission from a legally authorized person, if
  such substitute consent is permitted by law.
• In addition, the therapist (a) informs those
  persons who are legally incapable of giving
  informed consent about the proposed interventions
  in a manner commensurate with the persons
  psychological capabilities, (b) seek their assent
  to those interventions, and (c) consider such
  persons preferences and best interested.
• Adapted from APA (1992, p. 1605)

(Patrick, 129)
87
Common Elements in Treatment Planning

• Problem Identification Both the therapist and
  client must work together to identify and
  prioritize the most significant problems to work
  on during treatment. These problems must be
  defined in a manner that indicates how the
  problem exhibits itself in the client.
• Aims and Goals Treatment must always be
  directed to achieving for the client. An aim can
  be defined as the single overall desired outcome
  of a period of therapy. A goal is a subsidiary
  objective or end point of therapeutic work that
  is one of the components needed to realize the
  aim. Multiple goals may need to be achieved in
  order to achieve the aim of treatment.

(Patrick, 130-131)
88
Common Elements in Treatment Planning

• Strategies and Tactics A strategy refers to the
  general process or approach that the therapist
  will use to move the client toward an objective
  it is the therapeutic modality selected to attain
  an objective that is necessary to achieve in
  order to accomplish the goal of treatment. A
  tactic is a specific task that is undertaken or a
  technique used within the context of the strategy
  to help meet the objective. Multiple strategies
  can be sued to achieve an objective similarly,
  multiple tactics can be employed within each
  strategy.
• Flexibility Treatment planning should be
  approached with a flexible approach so that a
  change in the case formulation based on
  additional information or a lack of
  responsiveness to an existing course of treatment
  prompts the evaluation and possible modification
  of the treatment plan.

(Patrick, 131-132)
89
Recommended Content for a Treatment Plan

• Presenting Problem
• Problem List
• Diagnosis
• Goals and Objectives
• Treatment
• clients Strengths
• Potential Barriers to Treatment
• Any Referrals
• Criteria for Treatment Termination or Discharge
• Responsible Staff
• Treatment Plan Review Data

(Patrick, 133)
90
Treatment Plan ContentPresenting Problem

• The treatment plan should contain a statement
  about the problem for which the client is seeking
  treatment.
• The presenting problem of complaint should always
  be documented in the clients own words.
• The clients own problem description frequently
  can convey more information about themselves, the
  intensity of the problem, and how these problems
  affect their life then the clinicians could ever
  hope to communicate.
• It is important to remember that one of the
  purposes of the treatment plan is to serve as a
  vehicle for communicating with others. Thus,
  when the clients statement is not sufficiently
  clear or informative, the therapist can always
  provide clarification of what the client actually
  meant to convey or what was implied in their
  response to the questions regarding the reason
  for treatment.

(Patrick, 134)
91
Treatment Plan ContentProblem List

• A thorough assessment of the client can reveal
  any number of problems.
• Problems that are judged by any of the potential
  referring parties to (a) have a significant
  impact on the clients ability to function
  appropriately and adequately in any sphere of
  life (e.g., family, social, work, school), and to
  (b) be amenable to behavioral health care
  intervention should be listed here.
• Recognizing that the treatment plan is a
  communication tool, the identified problems
  should be stated in clear and unambiguous
  language.
• For example, problems in school could mean a
  lot of things for a given client, instead
  academic underachievement, disruptive behavior
  during class, for aggressive behavior outside
  the classroom provides a better description of
  the problem(s) that would be the focus of the
  treatment.

(Patrick, 134)
92
Types of Identified Problemsclient Identified
Problems

• clients should be able to identify one or more
  problems that they would like to work on in
  treatment. It may be necessary for the clinician
  to assist the client in verbalizing exactly what
  the problems are, based on the information
  obtained during the assessment. When this
  happens, the clinician should always seek the
  clients validation of any interpretation of what
  they are trying to convey.

(Patrick, 135)
93
Types of Identified ProblemsReferral Source
Identified Problems

• In most instances, the source of the clients
  referral to treatment will have one or more
  specific problems that the referring person /
  organization thinks require the attention of the
  behavioral healthcare professional.

94
Types of Identified ProblemsOther Identified
Problems

• Frequently there will be problems that the
  clinician identifies that did not come from
  another source. These are problems that the
  clinician has noted and judged to be having a
  significant impact on the clients functioning.
  Severe psychiatric symptomatology (e.g.,
  hallucinations, delusions, clinical depression),
  substance abuse or dependence, extensive use of a
  particular defense mechanism (e.g., denial), and
  impaired marital functioning are a few examples
  of behaviors that clients or their referral
  sources may not be aware of as existing or as
  being problematic.

(Patrick, 135)
95
Treatment Plan ContentProblem List

• Once the problem list is compiled, it then
  becomes important to verify that all of the
  problems (a) are understood and conveyed in clear
  language, (b) significantly impair the clients
  ability to function in some important sphere of
  life, and (c) are amenable to therapeutic
  intervention.

(Patrick, 136)
96
Treatment Plan ContentProblem List,
Prioritizing Problems

• A number of factors should be considered when
  prioritizing the final problem list
• The degree and extent to which the problems
  impact the clients life.
• The clinician should identify and determine which
  problems must be dealt with first in order to
  achieve a resolution of the problem to which many
  or all of the identified problems are tied.
• The clinician must identify those problems that
  can be dealt with relatively easily. Quick
  resolution of one or more of these problems in
  the early phases of treatment can provide the
  client with a sense of accomplishment and mastery
  that will reinforce those early efforts, instill
  a sense of hope, and encourage continued efforts
  in working on more difficult problems.

(Patrick, 137)
97
Treatment Plan ContentProblem List,
Prioritizing Problems

• Regardless of the relative importance of
  other-identified problems, the clinician should
  always give special consideration to those
  problems identified by the client. This
  acknowledges their importance to the treatment
  planning process.
• It is important to remember that prioritizing
  problems is a collaborative effort between the
  clinician and the client, thus the clients
  involvement in this process is critical.

(Patrick, 136-137)
98
Problem List, Prioritizing Problems Questions
to Consider

• What problems does the client identify as being
  the most troublesome or the primary reason for
  seeking help?
• Which of the identified problems must be dealt
  with first in order to resolve the central
  problem?
• Which problems can provide the client with an
  opportunity to easily and quickly experience a
  sense of success and mastery early in the
  therapeutic process?
• If the client had only 1 treatment session
  available and could work on only 1 problem during
  that session, which problem would you as the
  clinician choose?
• If the client had only 1 treatment session
  available and could work on only 1 problem during
  that session, which problem would the client
  choose?

(Patrick, 136)
99
Treatment Plan ContentProblem List, Limiting
Problem List

• There may be clients who have a large number of
  problems, of which resolution of all of them in a
  timely manner may not be possible due to
  limitations imposed by the clients payer, the
  probably of keeping the client engaged in
  treatment over an extended period of time, a
  planned relocation outside the local geographical
  area, the clients reluctance to work on all
  identified problems, or any of a number of other
  variables.

(Patrick, 137)
100
Treatment Plan ContentProblem List, Limiting
Problem List

• The clinician should consider limiting the stated
  problem list to include only the more highly
  prioritized problems that can fully and
  effectively be treated under the imposed
  limitations of the specified program or payer.
  Doing this keeps the treatment plan grounded in
  reality and is consistent with setting realistic
  expectations for the client.

(Patrick, 137)
101
Treatment Plan ContentDiagnosis

• The clinician should ensure that they have
  provided complete information for all five axis
  and these diagnoses are reflective of the
  information gathered in the assessment process
  and reflect the problem areas as verbalized by
  the client.

102
Treatment Plan ContentGoals and Objectives

• Goals should indicate the desired positive
  outcome to the treatment procedure. Goals are
  achieved through a series of objectives.
• Objectives should be stated in behaviorally
  measurable language. Objectives should be
  written in such a way that it is clear when the
  client has achieved it. Each objective should be
  developed as a step toward attaining the broad
  treatment goal.
• Each objective should be accompanied by a time
  line for completion.
• When all objectives are met for a specific goal,
  the goal is considered completed.

(Patrick, 138)
103
Goals and ObjectivesAchievable

• Among one of the most important characteristics
  of the goal or its associated objectives, is
  whether or not it is achievable.
• Given the resources and circumstances, are they
  something that the client is capable of
  accomplishing?
• If it is an achievable goal or objective, will
  the client be able to accomplish it within a
  reasonable time line?
• Unachievable goals, objectives, or time lines
  should always be avoided. These set up the
  client for failure and the possibility of
  premature treatment termination.

(Patrick, 139)
104
Goals and ObjectivesRealistic

• Once you have determined that the goals and
  objectives are achievable in a timely manner, the
  next question to ask yourself is how realistic
  that goal, objective or time frame is. The
  following questions can be used to determine if
  they are realistic
• Does the client have the motivation to do the
  work that is required?
• Does the client have a support system to assist
  them?
• Regardless of the clients ability to achieve the
  goal or objective in the time frame, the reality
  of the situation must be taken into consideration
  when determining whether a specific goal,
  objective, or time frame should become part of
  the treatment plan.

(Patrick, 139)
105
Goals and ObjectivesMeasurable

• Goals and objectives should be stated in
  measurable terms.
• In order to be measurable, goals and objectives
  should be quantifiable, specific and easily
  understood by the client and all stakeholders.
• Measurability allows for tracking client progress
  through the treatment process, providing
  information regarding the effectiveness of the
  treatment plan.
• Additionally, measurability allows the client to
  see for themselves where they started treatment
  and what they have accomplished through the
  treatment process, providing an incentive for
  continued participation in treatment.

(Patrick, 13-140)
106
Goals and ObjectivesStated in the Positive

• Whenever possible, goals should be stated in the
  positive (e.g., Increase the clients level of
  self-esteem). This conveys an effort to move
  towards improvement in the clients life rather
  than a movement away from something that is
  having a negative effect.
• Statements in the positive reinforces the idea
  that the client is striving to gain something
  rather than lose something.
• It is often difficult to attain a positive goal
  without eliminating or reducing one or more types
  of behaviors, emotions, or cognitions, it is
  appropriate to state objectives in the negative.

(Patrick, 140-141)
107
Goals and ObjectivesPrioritization

• Just as it is important to prioritize the
  clients problems, the goals and objectives
  should be prioritized.
• The priority should be given to the goals and
  objectives should mirror the priority assigned to
  the problems.
• Regardless of the various priority levels of the
  goals, the client can work toward achieving one
  or more goals at a time.
• Objectives tied to two or more goals can also be
  address simultaneously.
• Working on goals and objectives simultaneously
  represents the most efficient use of the clients
  and the therapists time.

(Patrick, 141-142)
108
Questions to Consider when setting Goals and
Objectives

• What do you see as your biggest problem?
• Do you think there is an immediate crisis that
  needs to be addressed?
• What do you see as your biggest goal in
  treatment?
• How will you know if you have achieved your goal?
• Does the goal involve changing things about
  yourself?
• Does the goal involve changing things about other
  people?
• What problems do you anticipate in reaching that
  goal?
• How will you be different after reaching the
  goal? What positive things will you be doing?
  What negative things will no longer be present?
• What skills will help you achieve the goal?

(Patrick, 141)
109
Treatment Plan ContentTreatment

• Following the listing of problems, goals,
  objectives and time frames is the plan for how
  the therapist will assist the client in resolving
  their problems and consequently achieving their
  goals and objectives.
• For clinicians who strictly adhere to a single
  therapeutic approach (e.g., cognitive-behavioral
  therapy), the interventions will generally be the
  same for all clients, regardless of what the
  problems are.
• The selection of the intervention to be used
  becomes more of a challenge for those therapists
  who are more eclectic in their treatment
  orientations.

(Patrick, 142)
110
TreatmentCo-Occurring Disorders

• Treating clients with one or more co-occurring
  disorders can present difficult challenges for
  the therapist.
• Co-occurring disorders and the barriers that they
  can impose must be considered when developing an
  effective plan of treatment.
• Co-occurring medical conditions, particularly
  those that are frequently accompanied by
  depression, anxiety, or other psychiatric
  symptoms may require special attention during
  treatment plan development, and referral to a
  medical provider if the condition remains
  untreated or appears to be out of control.

(Patrick, 155-156)
111
TreatmentCo-Occurring Disorders

• It is important to consider carefully the
  physical and psychological symptoms that
  accompany the disease or disorder and that
  potentially interfere with the type of treatment
  that would otherwise be prescribed for the client.

(Patrick, 156)
112
TreatmentAppropriate Level of Care

• One of the first considerations in planning for
  the treatment of a client is the level of care
  (LOC) that is most appropriate, given the
  clients particular circumstances.
• The factors that should play into a decision
  about LOC is the severity of the problem, the
  type of treatment that is most effective and most
  appropriate for the problem intensity level, and
  the least restrictive, along with the
  availability of the treatment.
• The more restrictive LOCs are typically used to
  stabilize the client or help ensure their safety.
• Accompanying the determination of the most
  appropriate LOC for the client is the assumption
  that there is a DSM-IV Axis I disorder present,
  that the assigned LOC can provide the type of
  treatment the client needs, and that it is the
  least restrictive LOC available.

(Patrick, 158)
113
Treatment Frequency and Duration of Treatment

• Treatment plans should indicate the frequency and
  duration for which the client will be seen in
  treatment.
• In some instances, statements regarding the
  frequency and duration may be nothing more than
  guesses based on the therapists experience with
  similar clients, problems and treatment goals.
• Generally, open ended treatment durations should
  be avoided except in cases for which long-term or
  continuous treatment is approp