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

By Diane R. Gehart

1st Edition © 2016
Discipline:Counseling
Course:Field/Practicum/Internship
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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.

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About this product

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.

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.

Table of contents

Chapters

Dedication
Brief Contents
Contents
Preface
Acknowledgements
About the Author
Part I: Introduction to Case Documentation
Part II: Theory-Informed Case Documentation
Part III: The Competent Supervisee
Index

Part I: Introduction to Case Documentation

Ch 1: Introduction to Case Documentation
Preview this section ↗
Making a Difference-Competently ↗
The Road to Competent Counseling ↗
Engaging Case Documentation Mindfully ↗
How This Book is Different and What It Means to You ↗
Suggested Uses for This Text ↗
Questions for Personal Reflection and Class Discussion ↗
Online Resources for Students ↗
Online Resources for Instructors ↗
References ↗
Ch 2: Case Conceptualization
Map the Territory: Case Conceptualization
Elements of Case Conceptualization
Introduction to Client
Presenting Concern
Background Information
Assessment of Strengths and Diversity
Theoretical Conceptualizations
Psychodynamic and Adlerian Conceptualization
Humanistic-Existential Conceptualization
Cognitive-Behavioral Conceptualization
Family Systemic Conceptualization
Postmodern-Feminist Conceptualization
Case Conceptualization, Diversity, and Sameness
Questions for Personal Reflection and Class Discussion
Online Resource
References
Case Conceptualization Form
Ch 3: Introduction to Clinical Assessment and Diagnosis
Step 2: Identify Oases and Obstacles
Lay of the Land
Clinical Assessment and Diagnosis
Clinical Assessment and Diagnosis: Limitations and Cautions with Diversity
Counseling Models and Diagnosis: Philosophical and Practical Concerns
Contemporary Issues in Diagnosis
Introduction to Changes in the DSM-5
Counseling Approach to Clinical Assessment
Diagnostic Reflections
Questions for Personal Reflection and Class Discussion
Online Resources
References
Ch 4: Completing a Clinical Assessment
Clinical Assessment Form
How to Complete a Clinical Assessment
Mental Status Exam and Diagnosis
Risk Management
Case Management
Communicating with Other Professionals
Mental Status Terms
Questions for Personal Reflection and Class Discussion
Online Resources
References
Ch 5: Treatment Planning
More Than a Number
Step 3: Select a Path
The Brief History of Mental Health Treatment Planning
Clinical Treatment Plans
Writing Useful Treatment Tasks
Writing Useful Client Goals
Writing Useful Interventions
Client Perspectives
Do Plans Make a Difference?
Questions for Personal Reflection and Class Discussion
Online Resource
References
Ch 6: Progress Notes
Step 4: Document It
On a Different Note: Progress versus Psychotherapy Notes
Progress Notes
Progress Note Ingredients
How to Complete a Progress Note
A Time and Place for Progress Notes
Final Note on Notes
Questions for Personal Reflection and Class Discussion
Online Resources
References
Ch 7: Evaluating Progress in Counseling
Step 5: Evaluating Progress
Nonstandardized Evaluation of Progress
Standardized Evaluation of Progress
Assessment in a Diverse Society
Real-World Options for Standardized Evaluations of Progress
Ultra-Brief Measures
Brief Measures
Final Thoughts on Assessing Client Progress
Questions for Personal Reflection and Class Discussion
Online Resources
Other Resources
References

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