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Case Documentation in Counseling and Psychotherapy: A Theory-Informed, Competency-Based Approach 1st Edition

Diane R. Gehart

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  • STARTING AT $12.99

  • ISBN-10: 1305844521
  • ISBN-13: 9781305844520
  • STARTING AT $21.49

  • ISBN-10: 1305405218
  • ISBN-13: 9781305405219
  • Bookstore Wholesale Price $62.00
  • RETAIL $82.95


CASE DOCUMENTATION IN COUNSELING AND PSYCHOTHERAPY teaches counselors and psychotherapists how to apply counseling theories in real settings. Written in a clear style, content introduces case documentation using four common clinical forms: case conceptualization, clinical assessment, treatment plan, and progress note. These documents help new practitioners understand how to use theory in everyday practice. Case studies illustrate how to complete documentation using seven counseling models. This resource overviews theories, conceptualization, treatment planning, and documentation. Case documentation assignments created using national standards help students apply concepts and develop professional skills.

Diane R. Gehart, California State University, Northridge

Dr. Diane R. Gehart is a Professor in the Marriage, Family, and Therapy and Counseling Programs at California State University, Northridge. She has authored numerous books, including CASE DOCUMENTATION IN COUNSELING AND PSYCHOTHERAPY, THEORY AND TREATMENT PLANNING IN COUNSELING AND PSYCHOTHERAPY, MINDFULNESS AND ACCEPTANCE IN COUPLE AND FAMILY THERAPY, and MASTERING COMPETENCIES IN FAMILY THERAPY. She also co-edited COLLABORATIVE THERAPY: RELATIONSHIPS AND CONVERSATIONS THAT MAKE A DIFFERENCE, and has developed two systems for assessing student learning: THE COMPLETE MFT CORE COMPETENCY ASSESSMENT SYSTEM and THE COMPLETE COUNSELING ASSESSMENT SYSTEM. Dr. Gehart's areas of specialty include mindfulness, mental health recovery, postmodern and systemic therapies, sexual abuse treatment, gender issues, children and adolescents, client advocacy, qualitative research, and education in family therapy. She speaks internationally, having conducted workshops to professional and general audiences in the United States, Canada, Europe, and Mexico. Her work has been featured in newspapers, radio shows, and television worldwide. She is an associate faculty member at three international post-graduate training institutes: The Taos Institute, Houston Galveston Institute, and The Marburg Institute for Collaborative Studies in Germany. Additionally, she is an active leader in state and national professional organizations. She maintains a private practice in Agoura Hills, California, specializing in couples, families, trauma, life transitions, and difficult-to-treat cases.
  • Clinical Forms: The book provides a comprehensive set of four clinical forms that can be used in practice environments, either in university training clinics or community agencies. The forms support theory-informed case conceptualization; clinical mental health assessment and DSM-5 diagnosis; treatment plans that incorporate theory, diversity, and evidence-based practice; and HIPAA-compliant progress notes.
  • Practical Applications to Diversity: Each clinical form requires students to identify specific ways that the treatment will be adjusted to address diversity issues, including the formation of a counseling relationship, assessment, and intervention.
  • Research and the Evidence Base: The evidence-base and research foundations for each theory are reviewed, and numerous evidence-based treatments are highlighted throughout the book.
  • Case Studies on Counseling Models: Comprehensive case studies illustrate how to complete documentation using each of seven counseling models: psychodynamic, Adlerian, humanistic, cognitive-behavioral, family systemic, solution-focused, and postmodern/feminist.
  • Readable: The author writes in a down-to-earth and often entertaining style that students will appreciate.
  • Website: The website has all clinical forms used in the book available free as a digital download. Additionally it has PowerPoint’s, an Instructor’s Manual and a Test Bank, all of which align to the national standard rubric.
  • Outcome-Based Pedagogy: This text teaches the skills and knowledge outlined in accreditation standards for counselors, psychologists, social workers, and family therapists.
  • Assessment of Student Learning: Using four clinical documentation forms, this text enables faculty to easily measure students' mastery of competencies and learning outcomes, which are now required for both regionally accredited university boards (WASC, SACS, etc.) and professional accrediting bodies (APA, CACREP, COAMFTE, and CSWE). Assessments with scoring rubrics correlated to each discipline's competencies are part of the ancillary materials.
  • Comprehensive Treatment Model: A comprehensive five-step model for competent treatment provides students with a clear map for their work. The model includes (a) theory-informed case conceptualization, (b) clinical assessment (diagnosis) and case management, (c) treatment planning, (d) evaluation of progress, and (e) progress note documentation.
  • Theory-Based Case Conceptualizations: The cross-theoretical case conceptualization form enables counselors to do a comprehensive case conceptualization for clients; the form can also be used in segments to create theory-specific conceptualizations.
  • DSM-5 Clinical Assessment: The clinical assessment form uses the DSM-5 diagnosis format and includes a mental status exam, crisis assessment, a safety plan, and case management.
  • Theory-Specific Treatment Plan Templates: Each theory chapter provides practical treatment plan templates for use with individuals struggling with depression or anxiety. These templates will better enable therapists to develop thoughtful, theory-based treatment plans for their clients.
  • Theory-Specific Progress Notes: The book presents a detailed introduction to HIPAA-compliant progress note format, including CPT codes.
  • Theory Considerations and Adaptations with Diversity Clients: The diversity sections in each theory chapter include specific, practical applications of the theory with specific populations. Each chapter contains a discussion of ethnic/racial diversity as well as sexual identity diversity. Expanded sections provide students with detailed suggestions, adaptations, and cautions for using a given theory with specific populations, including African-Americans, Hispanics/Latinos, Asian-Americans, Native Americans/First Nations/Aboriginals, and LGBTQ individuals.

Case Documentation in Counseling and Psychotherapy: A Theory-Informed, Competency-Based Approach


1. Introduction to Case Documentation.
2. Case Conceptualization.
3. Clinical Assessment.
4. Treatment Planning.
5. Progress Notes.
6. Evaluating Progress in Counseling.
7. The Competent Supervisee.
8. Psychodynamic Counseling and Psychotherapy.
9. Individual Psychology and Adlerian Counseling.
10. Humanistic-Existential Counseling Approaches.
11. Cognitive-Behavioral Approaches.
12. Systemic Family Counseling and Therapy.
13. Solution-Based Counseling.
14. Postmodern and Feminist Counseling Approaches.