Chapter 4DSM-IV-TR in Action

Advanced Studies in Mental DisordersEPSY 6395Dr. Sparrow

Documentation and Treatment Planning

The initial diagnostic assessment is necessary as a foundation for effective treatment

Documentation is paramount

problems

goals

objectives (behavioral)

interventions

action taken/progress

CATCH-22 for You!

Documentation is necessary, but how much is too much?

Do you have time to do it? If not, is that your problem, or a problem in the approach?

What is the consequence of extensive documentation?

Overload, shift of focus from therapy to defensive practice

What is the consequence of documenting too little?

More time to do therapy.

Risk of being found deficient in observing customary professional standards.

Expectations of Third Party Payors

Establish that the problem is sufficient serious so that treatment is “medically necessary.”

Diagnosis must be serious enough to warrant treatment

Treatment plan must correspond to the usual treatment for such problems, in order to justify reimbursement.

SOAP, Soapie, Soapier

Subjective--overall subjective assessment

Objective--measurable data, statements in quotes, observed behaviors during session.

Assessment

Plan--intervention plus any ancillary services and referrals for other services

Implementation--factors affecting the ability to carry out plan

Evaluation

Client response

Summary of Recording Formats

No matter system you choose, you will need to do these generic steps:

Start with Description of Presenting Problem

Conduct assessment of client in relationship to the problem

Develop strategy for intervention or treatment, or plan, which should have some estimation of time or sessions required.

Carry out Implement plan according to the time frame.

Evaluate client response and progress

Revise plan accordingly, and change diagnosis, treatment and time frame as needed.

Documentation

An issue that makes most people nervous!

It helps to have a form that requires you to be brief!

But be thorough!

Always ask, What would happen if an attorney read these notes?

Be careful about modifying records! This is a “red flag” for possibly litiginous parties.

Documentation

Security issues for computer based record keeping

passwords are stored in separate place

make regular backups store them in a “cloud” system, or in a separate location

use initials instead of full names in case notes

Documentation

Always date the progress note

Focus on the problem that the client has

Assess based on evidence

Treatment with goals, objectives, and interventions

Sign

Keep record as protection against possible litigation

Do not hide corrections or changes: make them very evident

Documentation:Sample Progress Note form

Documentation:Treatment Plan

Identify problem behaviors, especially those that impair social and occupational functioning

Do not include any irrelevant symptoms (e.g. Don’t include, “Mr. J. reports accessing adult porn sites in spare time” if focus is difficulty relating to people at work.)

Link interventions to problems (e.g. “Cognitive restructuring to address depressive symptoms tied to self-critical self talk)

Involve family and support system

Revisit and revised the treatment plan.

Documentation:Sample Treatment Plan for ADHD

Intervention Frameworks

Intervention frameworks have to be consistent with your theoretical rationale for practice. That is, if you are a Solution-Focused therapist, you will not want to use psychodynamic therapy, and vice versa.

All intervention strategies should emphasize self motivation and empowerment, rather than deficiencies. Egan said that counseling should be “to assist the client in solving problems in living by identifying unused or underused personal resources.”

Some disorders respond better to certain interventions. You should be trained sufficiently to be able to adjust the intervention to suit the diagnosis, or be ready to refer the client to someone else if the client needs an intervention for which you have not been trained.

Brief Therapy

In today’s market, brief therapy is valued highly, not only by insurance companies, but also by clients who want the most cost-effective and time-limited methods. Research shows that there is a “diminishing return” from long-term therapy.

Brief methods are based on the idea that the client is capable of enacting changes if given the right support and direction.

Focus is on the immediate past, and future.å

Little emphasis is placed on insight. It doesn’t matter what you think about it, it’s what you do about it.

Very active approaches involving homeword

Termination is discussed early. “How will you know when you’re ready to stop? What needs to happen first?”

Brief Therapy

Focus is on outcome, not process. The question is, Where do you want to go? not How do you want to get there?

In cognitive therapy, the emphasis is on assessing the client’s schema and then developing a multimodal approach to resolve the distortions that are causing distress.

In crisis intervention, the therapist focuses on the immediate problem and strategies for dealing with it. A sense of helplessness often accompanies a crisis, so crisis intervention methods are designed to reestablish a sense of hope and power by taking concrete steps.

In psychodynamic therapy, the therapists examines the behavior in light of past, unacknowledged trauma that may be at the root of the presenting problem.

Brief Therapy

In educative counseling, therapist works with imparting information that can make the difference in caring for oneself.

In Solution-focused therapy , the therapist examines the client’s recent past for the presence of time periods in which the problem was not apparent in order to discover what the client was doing then to make a difference. Thus, the therapist searches for competencies that are already in place, and supports the client in applying the particular skill or competency to the presenting problem.

Summary

Therapy ultimately revolves around an art that cannot be reduced to words, or documented for others to see.

General factors that should guide the diagnosis, treatment, and practice strategy:

1) clients need to be involved and motivated

2) diagnostic information will guide the methods

3) values and beliefs must be considered

4) culture and ract must be considered

5) The approach that we adopt should focus on client strengths and competencies