Case Documentation in Counseling and Psychotherapy

Dedication......Page 5
Brief Contents......Page 6
Contents......Page 7
Preface......Page 17
Acknowledgements......Page 21
About the Author......Page 23
Part I: Introduction to Case Documentation......Page 25
Making a Difference-Competently......Page 27
The Road to Competent Counseling......Page 28
Engaging Case Documentation Mindfully......Page 30
How This Book is Different and What It Means to You......Page 31
Suggested Uses for This Text......Page 35
Online Resources for Instructors......Page 38
References......Page 39
Map the Territory: Case Conceptualization......Page 41
Elements of Case Conceptualization......Page 42
Presenting Concern......Page 43
Background Information......Page 44
Assessment of Strengths and Diversity......Page 45
Theoretical Conceptualizations......Page 49
Psychodynamic and Adlerian Conceptualization......Page 50
Humanistic-Existential Conceptualization......Page 57
Cognitive-Behavioral Conceptualization......Page 62
Family Systemic Conceptualization......Page 65
Postmodern-Feminist Conceptualization......Page 69
Case Conceptualization, Diversity, and Sameness......Page 72
References......Page 73
Case Conceptualization Form......Page 75
Lay of the Land......Page 83
Clinical Assessment and Diagnosis......Page 84
Clinical Assessment and Diagnosis: Limitations and Cautions with Diversity......Page 85
Counseling Models and Diagnosis: Philosophical and Practical Concerns......Page 87
Contemporary Issues in Diagnosis......Page 89
Introduction to Changes in the DSM-5......Page 92
Counseling Approach to Clinical Assessment......Page 98
References......Page 101
Clinical Assessment Form......Page 103
Mental Status Exam and Diagnosis......Page 108
Risk Management......Page 109
Case Management......Page 112
Communicating with Other Professionals......Page 113
Mental Status Terms......Page 114
Online Resources......Page 116
References......Page 117
More Than a Number......Page 119
The Brief History of Mental Health Treatment Planning......Page 120
Clinical Treatment Plans......Page 121
Writing Useful Treatment Tasks......Page 124
Writing Useful Client Goals......Page 126
Writing Useful Interventions......Page 131
Do Plans Make a Difference?......Page 132
References......Page 133
On a Different Note: Progress versus Psychotherapy Notes......Page 135
Progress Notes......Page 136
Progress Note Ingredients......Page 137
How to Complete a Progress Note......Page 140
A Time and Place for Progress Notes......Page 143
References......Page 144
Step 5: Evaluating Progress......Page 145
Nonstandardized Evaluation of Progress......Page 146
Assessment in a Diverse Society......Page 147
Real-World Options for Standardized Evaluations of Progress......Page 149
Ultra-Brief Measures......Page 150
Brief Measures......Page 152
Questions for Personal Reflection and Class Discussion......Page 154
References......Page 155
Part II: Theory-Informed Case Documentation......Page 157
Lay of the Land......Page 159
Psychodynamic Theory......Page 160
Putting It All Together: Psychodynamic Case Conceptualization and Treatment Plan Templates......Page 181
Tapestry Weaving: Working with Diverse Populations......Page 184
Evidence-Based Treatment: Brief Psychodynamic Counseling......Page 187
Questions for Personal Reflection and Class Discussion......Page 189
References......Page 190
Psychodynamic Case Study: Suicidal Thoughts at Midlife......Page 192
Lay of the Land......Page 213
Putting It All Together: Adlerian Case Conceptualization and Treatment Plan Templates......Page 225
Tapestry Weaving: Working with Diverse Populations......Page 228
Research and the Evidence Base......Page 232
Questions for Personal Reflection and Class Discussion......Page 233
References......Page 234
Adlerian Case Study: Trauma and Immigration......Page 236
Lay of the Land......Page 257
Person-Centered Counseling......Page 258
Gestalt Counseling......Page 271
Putting It All Together: Humanistic Case Conceptualization and Treatment Plan Templates......Page 280
Tapestry Weaving: Working with Diverse Populations......Page 283
Research and the Evidence Base......Page 286
Online Resources......Page 287
References......Page 288
Humanistic Case Study: Perfectionism and Anxiety......Page 290
Lay of the Land......Page 311
Cognitive-Behavioral Approaches......Page 312
Putting It All Together: Cognitive-Behavioral Case Conceptualization and Treatment Plan Templates......Page 332
Mindfulness-Based Approaches......Page 334
Tapestry Weaving: Working with Diverse Populations......Page 338
Research and the Evidence Base......Page 341
Questions for Personal Reflection and Class Discussion......Page 342
Online Resources......Page 343
References......Page 344
Cognitive-Behavioral Case Study: Child Abuse History and Bipolar Disorder......Page 346
Lay of the Land......Page 367
Putting It All Together: Systemic Treatment Plan Case Conceptualization and Treatment Plan Templates......Page 386
Bowen Intergenerational Family Approach......Page 389
Satir's Human Growth Model......Page 390
Tapestry Weaving: Diversity Considerations......Page 391
Questions for Personal Reflection and Class Discussion......Page 394
Online Resources......Page 395
References......Page 396
Systemic Case Study: Substance Use and Unemployed......Page 397
Solution-Based Counseling......Page 417
Putting It All Together: Solution-Based Treatment Plan Case Conceptualization and Treatment Plan Templates......Page 433
Tapestry Weaving: Working with Diverse Populations......Page 436
Research and the Evidence Base......Page 438
Online Resources......Page 439
References......Page 440
Solution-Based Counseling Case Study: Family Conflict over Biracial Relationship......Page 441
Lay of the Land......Page 463
Narrative Approaches......Page 464
Putting It All Together: Narrative Treatment Plan Case Conceptualization and Treatment Plan Templates......Page 475
Feminist and Cultural Theories......Page 478
Putting It All Together: Feminist Treatment Plan Case Conceptualization and Treatment Plan Templates......Page 487
Tapestry Weaving: Working with Diverse Populations......Page 490
Research and the Evidence Base......Page 493
Questions for Personal Reflection and Class Discussion......Page 494
References......Page 495
Postmodern Case Study: ADHD, Substance Use, Coming Out......Page 497
Part III: The Competent Supervisee......Page 517
What I Wish I'd Known before I Saw My First Client......Page 519
Managing Initial Anxiety......Page 520
Your Role as Supervisee: Proactive Learner......Page 522
Your Supervisor's Role: Realistic Expectations......Page 525
What to Know and Do before You Start Seeing Clients......Page 530
Getting the Most out of Supervision......Page 533
What to Do When or If Things Get Bumpy......Page 536
What to Look for When Applying for Field Sites......Page 539
The Competent Supervisee......Page 541
References......Page 542
Index......Page 545