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CASE DOCUMENTATION IN COUNSELING AND PSYCHOTHERAPY teaches counselors and psychotherapists how to apply counseling theories in real-world settings. Written in a clear, down-to-earth style, the text provides a comprehensive introduction to case documentation using four commonly used clinical forms: case conceptualization, clinical assessment, treatment plan, and progress note. These documents incorporate counseling theory and help new practitioners understand how to use theory in everyday practice. Case studies illustrate how to complete documentation using each of seven counseling models. Readers also learn about the evidence base for each theory as well as applications for specific populations. More than a text, this book can be used as a clinical reference manual by mental health professionals, providing practical overviews of theories, conceptualization, treatment planning, and documentation. Designed to produce measurable results that have value beyond the classroom, the text employs learning-centered, outcome-based pedagogy to engage students in an active learning process. Its case documentation assignments-created using national standards-help students apply concepts and develop professional skills early on in their training. Instructors are supported by syllabi templates, PowerPoint® slides, test banks, online lectures, scoring rubrics designed for accreditation assessment, and more.
- 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.
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.
Part II: THEORY-INFORMED CASE DOCUMENTATION.
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.
“This text truly helps develop competent practitioners and is an invaluable resource to both the student and seasoned clinician alike.”
“I have told a couple of colleagues of mine about the text as I have been reviewing it over the last few days. I am coordinator of a counseling program, and this is the type of textbook that we are looking to incorporate. The examples and case studies are what students in the era need to help them grow as counselors.”