1
Q
VII. Mental Status Evaluation
General Behavior
A
- Cooperative, passive, withdrawn, dramatic, hostile, restless
2
Q
VII. Mental Status Evaluation
Attire
A
- appropriate, seductive, untidy, loud, meticulous
- Be especially aware of attire change from session 1 to session 2 b/c if you are found attractive by your client, they could “swim their way through Old Spice” on the way to your second session
3
Q
VII. Mental Status Evaluation
Facial expression
A
- unremarkable, sad, angry, perplexed, fearful, elated, immobile, grimacing
4
Q
VII. Mental Status Evaluation
Posture
A
- rigid, erect, lump, slouchy
5
Q
VII. Mental Status Evaluation
Gait
A
- normal erect, stooped, ataxic, rigid, shuffling, manneristic
6
Q
VII. Mental Status Evaluation
Motor activity
A
- normal, agitated, tremor, tic, mannerisms
7
Q
VII. Mental Status Evaluation
Stream of Thought
A
- how do they go from one thought to the next
8
Q
VII. Mental Status Evaluation: Stream of Thought
Productivity
A
- spontaneous, verbose, pressured speech, mute
9
Q
VII. Mental Status Evaluation: Stream of Thought
Progression
A
- normal, loose, circumstantial (going in circles),
- perseveration (everything goes back to the reason they came in, always going back to that),
- halting, blocking, incoherent, fragmented
10
Q
VII. Mental Status Evaluation
Language
A
- normal, baby talk, peculiar expression, stilted
11
Q
VII. Mental Status Evaluation: Emotional Tone and reaction
Affect
A
- indifferent, fearful, angry, euphoric,
- shallow (they act like they get it, but they don’t),
- blunt, flat, normal, composed, anxious, sad, tearful,
- labile (up and down)
12
Q
VII. Mental Status Evaluation: Mental trend/Content of thoughts
Perception
A
- normal,
- auditory hallucination,
- visual hallucination,
- depersonalization (experience of being outside of yourself, observing yourself in the situation),
- illusions,
- derealization (the attribution of non-human factors to people, so others are things rather than people),
- hypochondriasis
13
Q
VII. Mental Status Evaluation: Mental trend/Content of thoughts
Cognition
A
- obsessive and ruminative,
- preoccupied,
- self-depreciatory,
- idiosyncratic,
- stereotyped
14
Q
VII. Mental Status Evaluation: Mental trend/Content of thoughts
Cognition content
A
- (what are you obsessed about): obsessions, phobias, compulsive rituals, religiosity, ideas of reference (belief that inanimate objects are communicating with you)
- (i.e. a news reporter says “good night” when closing their news update and a person thinks that reporter is specifically talking to them),
- passivity feelings (feelings of non-person),
- nihilistic (pessimism/vague), delusions, self-derogatory delusions, suicidal ideation, bizarre ideas (thoughts of things that couldn’t happen) vs. non-bizarre ideas (thoughts of things that realistically could have happened),
- paranoid ideation (paranoid beliefs/thoughts)
15
Q
VII. Mental Status Evaluation: ● Orientation and Sensorium
Consciousness
A
- alert, clouded, fluctuating, stuporous, apathetic
- Patient should be “alert” when you send that bill to BCBS b/c they won’t pay for “stuporous”
16
Q
VII. Mental Status Evaluation: ● Orientation and Sensorium
Orientation:
A
- normal, disoriented to time/place/person
17
Q
VII. Mental Status Evaluation: ● Orientation and Sensorium
Memory:
A
- normal, impaired (remote/recent/immediate)
18
Q
VII. Mental Status Evaluation: ● Orientation and Sensorium
Digit Span
A
- forward (good-poor),
- backward (good-poor)
19
Q
VII. Mental Status Evaluation: ● Orientation and Sensorium
Disorder of:
A
- counting,
- calculation,
- reading,
- writing,
- apperception,
- attention,
- concentration,
- comprehension
20
Q
VII. Mental Status Evaluation: ● Orientation and Sensorium
General knowledge:
A
- consistent w/ education,
- inconsistent,
- able to abstract, concrete
21
Q
VII. Mental Status Evaluation: Orientation and Sensorium
Insight and judgment:
A
- good,
- poor,
- absent,
- superficial
22
Q
VII. Mental Status Evaluation: General Behavior/Gait
ataxic
A
- an inability to coordinate voluntary muscular movements;
- symptomatic of some nervous disorders
23
Q
VII. Mental Status Evaluation: Stream of Thought/Progression
loose
A
- difficulty staying on track
- jump from one thing to another
24
Q
VII. Mental Status Evaluation: Stream of Thought/Progression
blocking
A
- as they speak they completely lose their train of thought.
- In order to mask this they may use confabulation
- change the conversation in a dramatic way, begin making things up
- can be related to amnesia, early dementia and korsocoff’s syndrome
25
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Perception
depersonalization
* outside yourself
26
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Perception
hypochondriasis
* morbid condition about health, especially about death
27
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Perception
obsessions
* always refer to thoughts
28
# Why the emphasis on treatment plan?
Clinicians benefit
* Forced to think analytically about what we’re doing in each case
* Objective documentation in the event ofagainslitigation
* Needs of the client are primary (not projecting your issues on them)
29
# Why the emphasis on treatment plan?
Clients benefit
* Direction for treatment is clear (agreed upon direction of treatment)
* Outcomes are in focus and are generated FOR THE CLIENT
* Expectation of specific result
30
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Cognition Content
compulsive rituals
* always refers to behaviors [The compulsion resolves the obsession.]
31
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Cognition Content
religiosity
* to the extreme
32
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Cognition Content: ideas of reference
special messages for the person
* it is all about them, ie. books, the Bible
33
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Cognition Content
nihilistic delusions
* delusions of nothingness
34
# VII. Mental Status Evaluation: Mental Trend, Content of Thought/Cognition Content
should be added
* suicidal ideation
35
# VII. Mental Status Evaluation: Orientation and Sensorium/Memory
should be added:
* Digit Span: Forward (Good-Poor),
* Backward (Good-Poor);
* Disorder of: counting, calculation, reading, writing, apperception, attention, concentration, comprehension
36
# VIII. Integrated Summary [Client has gone home.]
Document what?
* medical, psychological, social and spiritual issues within the context of the illness
37
# VIII. Integrated Summary
A narrative that makes the points of the case without the details...
* should not bring up anything new
* summarizes what is already in the Biopsychosocial History
* only discuss details that make the case for the primary diagnosis
38
# VIII. Integrated Summary
MTP
* master treatment plan.
39
# VIII. Integrated Summary
Prognosis:
* it is wise to make this hopeful;
* it is unwise to make the prognosis hopeless.
* should always be good at the very least;
* writing down “poor” or “fair” may mean that the therapist feels a lack of confidence for the client
40
# VIII. Integrated Summary
Time:
* means beginning and end time!\*\*\*
* This is important due to liabilities in saying if they were in the office or not when they were or weren’t.
41
# VIII. Integrated Summary
FIRPP:
* focus,
* intervention,
* response,
* progress,
* plan.
42
# VIII. Integrated Summary : Patient Eligibility/Motivation for Clinical Services
Internal:
* Do NOT put “the patient has no motivation” b/c insurance won’t pay you;
* Do NOT put “sent by judge” or “court-ordered” b/c insurance won’t pay you
* the bill should go to the judge in their eyes
43
# VIII. Integrated Summary : Patient Eligibility/Motivation for Clinical Services
External:
* could be family, spouse, etc.
44
# VIII. Integrated Summary : Patient Eligibility/Motivation for Clinical Services
Limitations:
* often clients are lacking insight
45
# Treatment Planning
Psychological Testing (Treatment Recommendations):
* often not paid for by anyone except the person undergoing testing;
* rarely even used now except for with children
46
# Treatment Planning
Schedule history & physical with:
* typically utilized with substance abuse clients so we know how pervasive the symptoms are related to their physiological health
47
# Discharge Planning
Talking about discharge when?
* right at the beginning
48
# Discharge Planning
Typically use what type of language when talking about termination?
* “number of sessions” vs “anticipated discharge date”
* make it realistic and subject to change in the future
49
# BPS History: Discharge Planning
Discharge criteria:
* this is how you would know to discharge this client; you could write “when client’s mood has stabilized,”
* “when client has learned to manage the anxiety,”
* “when client is no longer disturbed by voices,” etc.;
* this doesn’t mean everything is now great for the client forever, but the reason they came to counseling has been dealt with
50
# BPS History: Discharge Planning
Anticipated aftercare plan:
* if its related to an addiction, you can write “continue to attend AA/NA,”
* if it’s anything else, you can write “return to PCP (write name of client’s PCP)”
51
# BPS History: Progress Note
Name for it?
* Called “FIRPP notes”
52
# BPS History: Progress Note
Focus:
* what was the focus/main themes of the session;
* **keep it clinical**
53
# BPS History: Progress Note
Intervention:
* what did you, as the therapist, do to help the client;
* do NOT write “I listened”; answer the question
* “How did you intervene?”;
* implied action here, not passivity;
* for example, you could say “we explored the idea of starting medication” and patient response was “let’s see how things go here for awhile, then I’ll come back to the idea”
54
# BPS History: Progress Note
Response:
* how the client responded to your interventions;
* you can document if the client didn’t accept/utilize/didn’t work with the interventions you used
* just make sure you don’t do those interventions again nor put them in the plan
55
# BPS History: Progress Note
Progress
* Details of what we’re working on and how we’re handling it
56
# Treatment Planning
1960s
* Barebones
* Psychodynamic therapy prevailed
* Objectives/treatment plans non-existent
* concerned more with unconscious behavior
* Therapist acted more as a tabula rosa and was more passive
* Lacked detail and direction (“just folks talking”)
* Simply “following” the client
* No treatment plan, per se
57
# Treatment Planning
1970s
* JCAHO (Joint Commission for the Accreditation of Healthcare Operations) standards established
* Accreditation
* must meet JCAHO standards
* Focus on:
* Quality of care
* Thoroughness
58
# Treatment Planning
1980s
* Managed Care = someone is “managing” you as you care for your clients
* Accountability to insurance companies
* Bit of a collision in the field
* psychodynamic went off to the side, in came behaviorism, CBT, REBT, etc. (these approaches were able to respond to the managed care approach)
59
# Treatment Planning
1990s
* Old Practice: “Follow the client”
* 90’s to Present: Treatment Plan guides the treatment process and tell us that before the insurance company pays you.
60
# The Treatment Plan Elements
Three things in a Treatment Plan:
* Problem,
* Goals,
* Objectives
61
# The Treatment Plan Elements
The Clinical Problems listed:
* Exactly what needs improvement
* (conceptualize the case, and pinpoint the central reason why they are there, avoid using diagnostic words)
* These needs must have been identified in the assessment
* The problem needs to be properly framed
* (ex. Mary’s mother died, but Mary is overwhelmed with grief due to her mother’s death, so grief is the issue to help, not the death
* ensures the client’s treatment gets paid for)
* Think about reframing problems described by clients in ways that suggest a solution.
* Don’t need to list every little problem, just write it in 1 sentence/phrase
* (i.e. client is experiencing periods of delusions/hallucinations)
62
# The Treatment Plan Elements
The Clinical Goals
* An expected result that takes time
* Is related to problems (the goal is always the direct opposite of the problem)
* Realistic and doable o Provides guidelines for direction of therapy
* Can be broad in scope and in nature (goals are broad, do not answer “how” – objectives are steps on “how to achieve”)
* Could say,
* “Dissolve depressive episodes,”
* “Learn to manage anxiety,”
* “Discontinue auditory hallucinations,”
* “Assist attention and focus (ADD diagnosis)”
* keep it concise and crisp
63
# The Treatment Plan Elements
Objective should be:
* Clearly stated/brief with clinical language.
* One variable
* Set out objectives separately
* Time-lined
* Realistic for the client
* Within control of the client
* Measurable
64
# Implications of treatment readiness
Low readiness
* Directive therapist
* RET or
* behavioral Modification
65
# Implications of treatment readiness
Moderate readiness
* Combined directive and supportive therapist
* Reality therapy
66
# Implications of treatment readiness
Implications of treatment readiness Moderately high readiness
Low directiveness and high support Promote understanding Client centered therapy
67
# Implications of treatment readiness
Implications of treatment readiness High treatment readiness
Limited directiveness sand support Observe and delegate responsibly Psychodynamic therapy
68
# Treatment Plan Elements: Types of Objectives
1. Recall or express knowledge of specific facts
* you can’t change what you don’t understand
* *i.e. Client will **define** alcoholism*
* Terms: define, choose, identify, indicate, complete, match, repeat
* all **action terms** and **basic information.**
* The most basic, fundamental type of objective.
69
AEB
* As evidenced by
70
# Treatment Plan Elements: Types of Objectives
2. Comprehension & understanding
* *i.e. Client will recognize his drinking pattern on the Jellinek chart*
* Terms: discuss, suggest, learn (internalizing knowledge)
71
# Treatment Plan Elements: Types of Objectives
3. Apply a principle or strategy
* i.e. The client will role-play an alcohol refusal strategy/relaxation strategies
* Terms: illustrate, demonstrate
* (applying the knowledge they have to a life situation.)
* This part is getting at how will the client deal with real-world situations
* (i.e. a recovering alcoholic gets confronted with a drink at a party → they need to know how to refuse a drink)
72
# Treatment Plan Elements: Types of Objectives
4. Analysis into the parts that are distinguishable
* i.e. Client will distinguish between shame and guilt.
* Terms: draw conclusions, analyze, distinguish (knowledge)
* Break things up into constituent parts
* the more we can distinguish btwn things, the better we can understand them
73
# Treatment Plan Elements: Types of Objectives
5. Evaluate with criteria internal or external entities
* i.e. Client will compare work performance prior to treatment with current performance;
* on a scale of 1-10 how were you when you first came to therapy and where would you rate yourself now
* Terms: judge, rate, measure (wisdom);
* ability to see progress over time
* We are evaluating progress here
74
# Treatment Plan Elements: Types of Objectives: General
Keep in mind....
* \*\*All the “terms” in the above types of objectives are important for treatment plans as proof of action\*\* \*\***Make sure the treatment plan has sprinkles of all the 5 levels\*\***
75
# Treatment Plan Elements: Intervention
What the clinician will do
* Know what theoretical orientation you gravitate towards without being a one-trick pony
* Selection from therapeutic repertoire of techniques available to you, as long as it is beneficial to the client
* If you do not know enough about their issue, refer them out
* Vehicle through which you deliver the objectives
76
# Treatment Plan Elements: Intervention
Master Treatment Plan
* Problem,
* then goal,
* then objectives
77
# Treatment Plan Elements: Intervention: Progress Notes: FIRPP
**F**IRPP
* **PROGRESS NOTES EVERY TIME YOU SEE THE CLIENT**
* Focus of session, needs to reflect one of the objectives being worked on
78
# Treatment Plan Elements: Intervention: Progress Notes: FIRPP
F**I**RPP
* **PROGRESS NOTES EVERY TIME YOU SEE THE CLIENT!**
* Intervention
* what counselor did
* (Did BCBS get value for their money?)
* (example: “Counselor explained how meds work and implications for taking meds routinely.”)
79
# Treatment Plan Elements: Intervention: Progress Notes: FIRPP
R
* **PROGRESS NOTES EVERY TIME YOU SEE THE CLIENT!**
* Response of the client
80
# Treatment Plan Elements: Intervention: Progress Notes: FIRPP
FIR**P**P
* **PROGRESS NOTES EVERY TIME YOU SEE THE CLIENT!**
* Progress, if any
81
# Treatment Plan Elements: Intervention: Progress Notes: FIRPP
FIRP**P**
* Plan
* what counselor will do next time based on response of client
82
# Treatment Plan Elements: Progress Notes
FIRPP purpose
* Record beginning and ending time of the session
* Often can use a form for progress notes
* If you send a bill to BCBS that isn’t substantiated by a progress note, it is fraud.
* Progress notes are legal documents; cannot leave a line blank, must draw a line thru it (like a personal check)
83
# Treatment Plan Elements: Intervention
Target Date
* target date of completion of therapy
84
# VERY IMPORTANT TO KNOW
What is included in the Biopsychosocial History?
* Identifying Data
* substance abuse evaluation
* psychological/emotional history
* childhood/development history and family of origin
* Social history
* social assessment
* mental status evaluation
* integrated summary
* treatment planning
* discharge planning
* progress note
*
DSM
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