Therapist's Guide to Clinical Intervention - Sigmund Freud

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XVI Contents Treatment Plan 439 Mental Status Exam 442 Contents of Examination 442 Mental Status Exam 444 Mental Status Exam 445 Initial Case Assessment 447 Initial Evaluation 449 Brief Mental Health Evaluation Review 451 Life History Questionnaire 454 Adult Psychosocial 463 Family History 464 • Drug and Alcohol Abuse 465 Educational History 465 • Employment History 465 Socialization Skills 465 Summary 466 Treatment Plans and Recommendations 466 Child/Adolescent Psychosocial 467 Identifying Information 467 Parent's Questionnaire 475 Question 475 Self-Assessment 477 Brief Medical History 478 Illnesses and Medical Problems 479 Medical Review Consult Request for Primary Care Physician of an Eating Disorder (EDO) Patient 480 Substance Use and Psychosocial Questionnaire 481 Treatment History 482 • Family History 483 Social History 483 • Medical Problems 484 Chemical Dependency Psychosocial Assessment 485 Initial Evaluation Consultation Note to Primary Care Physician 488 Brief Consultation Note to Physician 490 Outpatient Treatment Progress Report 491 Progress Note for Individual with Anxiety and/or Depression 494 Clinical Notes 496 Disability/Worker's Compensation 498 Social Security Evaluation, Medical Source Statement, Psychiatric/ Psychological 499 Worker's Compensation Attending Therapist's Report 500 Progress 500 • Treatment 500 Work Status 500 • Disability Status 500 Brief Psychiatric Evaluation for Industrial Injury 502 Brief Level of Functioning Review for Industrial Injury 505 Outline for Diagnostic Summary 509 Diagnostic Summary 509 Discharge Summary 511 Patient Registration 515
Page 2: Therapist's Guide to Clinical Inter
Page 6: Therapist's Guide to Clinical Inter
Page 10: CONTENTS Introduction xvii Level of
Page 14: Chapter 2 ASSESSING SPECIAL CIRCUMS
Page 18: Evaluation and Disposition Consider
Page 22: Ten Ways of Responding to Aggressio
Page 26: Low Self-Esteem 330 The Self-Esteem
Page 30: Couple's Conflict: Rules for Fighti
Page 36: This page intentionally left blank
Page 40: xx formulation that is individualiz
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Page 50: HIGH-RISK SITUATIONS IN PRACTICE Yo
Page 54: SOLUTION-FOCUSED APPROACH TO TREATM
Page 58: XXIX
Page 62: Treatment Planning-. Goals, Objecti
Page 66: Additional Considerations C. Identi
Page 70: PERVASIVE DEVELOPMENTAL DISORDERS (
Page 74: Developmental Stage 4. Visual/audio
Page 78: 3. Teachers A. Define classroom rul
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E. Lying 1. Identify the nature and
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Many children diagnosed with Attent
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Treatment Focus and Objectives 5. D
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D. Practice positive thinking and e
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As adequate nutrition and normal ea
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D. Facilitate understanding of feel
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Possible Signs and Symptoms of Anor
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Not being negatively judgmental abo
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3. Encourage separation and individ
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Kohlberg's theory of moral developm
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ORGANIC MENTAL SYNDROMES AND DISORD
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Treatment Focus 1. Refer for immedi
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2. Multi-infarct (vascular) Dementi
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PSYCHOACTIVE SUBSTANCE ABUSE DISORD
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E. Encourage person to take respons
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12. Dysfunctional Family Interactio
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Common Drugs of Abuse Type of drug
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SCHIZOPHRENIA, DELUSIONAL, AND RELA
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7. Sleep Disturbance A. Log sleepin
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PHASES OF TREATMENT 1. Acute phase
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MOOD DISORDERS C. Modality 1. Behav
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intentions that place others in a p
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10. Eating Disturbance A. Evaluate
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Co-occurance with Medical Illness C
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As with risk for injury or danger t
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3. Headache 4. Hypotension 5. Pulse
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8. Patronizing sex-oriented establi
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ANXIETY DISORDERS 2. Treatment of D
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E. Gradually decrease time allotted
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12. General Side Effects of Medicat
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2. Outcry A. Normal emotional respo
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O. Positive feedback and reinforcem
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PSYCHOSOMATIC ILLNESS AND PERSONALI
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B. Have you ever had burning sensat
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H. Facilitate identification of spe
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ADJUSTMENT DISORDERS C. Consult wit
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F. Identify problems associated wit
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B. Provide safe environment, and in
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Treatment Focus and Objectives 3. I
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AVOIDANT PERSONALITY DISORDER Goals
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4. Decrease ritual behaviors 5. Dec
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Treatment Focus and Objectives 7. D
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E. Encourage the person to keep a j
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Goals Treatment Focus and Objective
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Goals Treatment Focus and Objective
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Treatment Focus and Objectives Goal
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F. Develop appropriate alternatives
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STAGES OF ADJUSTMENT Adjusting to M
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Medical Causes of Psychiatric Illne
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Assessing Special Circumstances ASS
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Criteria for Major Depressive Episo
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CYCLE OF DEPRESSION Early life expe
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SUICIDE Assessing self-destructive
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18. Loss of family status (family m
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DANGEROUSNESS 7. Impulsive behavior
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B. Demographics 1. gender (males ar
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N. Positive reinforcement for effor
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OBSESSIONAL DISORDERS: AN OVERVIEW
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GRAVELY DISABLED The gravely disabl
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SELF-CARE SKILLS Assessing the leve
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opportunity as possible. As with al
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CRISIS INTERVENTION When a person e
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SCREENING FOR SURVIVORS The Institu
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3. Nightmares 4. Feelings of helple
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4. PTSD (near death trauma/disfigur
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4. Other difficulties a. Fluctuatin
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Postpartum Panic Disorder Symptom C
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7. Distract yourself A. Find someth
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B. Initiate a journal. Instead of k
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The interventions for medical crisi
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D. Feelings of low self-esteem and
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E. Facilitate a family discussion t
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2. Changes in self-image A. Identif
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J. Live life to its fullest K. Be i
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It would mean that at the location
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PAIN MANAGEMENT SCALE Medical under
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7. Identify thoughts and feelings o
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Individuals presenting with somatic
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EATING DISORDERS SCREENING QUESTION
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THE MOOD EATING SCALE EATING HISTOR
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F. Parental verbal abuse G. History
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D. Group therapy E. Specific eating
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Difficulty living beyond the moment
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ADHD BEHAVIORAL REVIEW Below are a
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CHEMICAL DEPENDENCY ASSESSMENT Date
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Mental Status: Mood Affect Memory P
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S.O. Relationships and History of C
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WITHDRAWAL SYMPTOMS CHECKLIST Ratin
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SPOUSAL/PARTNER ABUSE The victim of
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L. Centrality of partner M. Depress
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A General Systems Model of Domestic
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6. Victim symptom presentation A. D
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OBJECTIVES 1. Enhance experience of
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General Symptoms of Possible Child
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The purpose of the Bonding Study is
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H. Parent-Child Interaction 1. How
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CHILD'S OWN SCENARIOS These are exp
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1. Had little to do with the child
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H. Significant desire to withhold c
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QUESTIONS TO ASK THE PARENTS 1. Wha
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VISITATION RIGHTS REPORT When there
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PSYCHIATRIC WORK-RELATED DISABILITY
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4. Mental health history and releva
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PSYCHOLOGICAL PRE-EMPLOYMENT EVALUA
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FORENSIC EVALUATION The legal issue
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4. Referral Source 5. Relevant Back
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Skill-Building Resources for Increa
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The difference between being stress
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must be facilitated, followed by th
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4. Addictive behavior. Efforts to e
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TIPS TO SIMPLIFY LIFE E. Are you a
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PAIN MANAGEMENT HOW TO IMPROVE PLAN
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SELF-CARE PLAN 13. Set goals and re
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EMOTIONAL IQ 17. Stay with it. Pers
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MENTAL RELAXATION (5 TO 10 MIN) 1.
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BRIEF RELAXATION (5 TO 10 MIN) Get
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Notice the difference between tensi
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CONFRONTING THE PROVOCATION Stay ca
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STEP 5: The Word Words are powerful
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Implementing the process does not e
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ASSIGNMENT 3 Taking Risks 1. What i
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COMPONENTS OF EFFECTIVE COMMUNICATI
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NONVERBAL COMMUNICATION CHECKLIST B
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EFFECTIVE LISTENING 1. Focus on wha
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1. You are standing in line and som
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DEVELOPING ASSERTIVENESS 1. What do
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THE STEPS OF POSITIVE ASSERTIVENESS
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REVIEW FOR YOURSELF THE CONSEQUENCE
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WRITING may be isolated to specific
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LIST OF FEELING WORDS PLEASANT FEEL
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time will clarify your time managem
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GOAL DEVELOPMENT 5. Visualize your
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Distorted Thinking— Negative Self
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Thought-Stopping Practice 1. Close
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REALISTIC SELF-TALK 2. Overgenerali
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PRACTICE REFRAMING HOW YOU INTERPRE
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DEFENSE MECHANISM DEFINITIONS 1. De
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UNDERSTANDING ANGER 1. What are the
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RECOGNIZING THE STAGES OF ANGER It
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WAYS TO DEAL WITH ANGER 1. Recogniz
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Causes of Workplace Violence BULLY
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determining if acts of violence wil
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4. Lowering one's tone of voice or
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16. Recognize that work stress and
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4. What has prevented the necessary
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LOSSES/OPPORTUNITIES Sometimes chan
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GRIEF CYCLE (WHERE ARE YOU STUCK?)
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From this place of pain, hurt, and
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HISTORY OF LOSS GRAPH On your graph
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STEPS Begin observing which self-ta
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low self-esteem you tend to very ne
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RECOGNIZING THE STAGES OF DEPRESSIO
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DEPRESSION SYMPTOM CHECKLIST The sy
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SURVIVING THE HOLIDAY BLUES For som
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think unless you clearly understand
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alance the checkbook go for a walk
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CONFRONTING AND UNDERSTANDING SUICI
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FEELING OVERWHELMED AND DESPERATE W
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GUILT A person who is experiencing
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LONELINESS When a person feels that
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Describe the behaviors associated w
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TEN SELF-ESTEEM BOOSTERS 1. Be real
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3. You are able to be objective and
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Identify your characteristic of low
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WHAT MOTIVATES ME? STANDING UP TO S
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BAD MEMORIES AND FEAR Feeling depre
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What is your plan for managing this
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2. Imbalance in brain chemistry may
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MANAGING ANXIETY 3. Hypervigilance
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WHAT DO YOU DO Ineffective and dysf
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HOW YOUR BODY REACTS TO STRESS AND
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PLAN OF ACTION FOR DEALING WITH ANX
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In preparing yourself for the manag
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SYSTEMATIC DESENSITIZATION Systemat
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6. Endocrine abnormalities 7. Infec
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C. Children of a parent with schizo
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CAREGIVING OF ELDERLY PARENTS It ma
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B. Make amends when necessary C. Ev
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SLEEP DISORDERS 8. Anxiety and stre
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6. A normal pattern of sex can be h
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ASSESSING LIFESTYLE AND HEALTH A. C
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IMPROVING YOUR HEALTH Ready to turn
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4. What resources may be helpful in
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c. Protecting your food supply; hid
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A. May cause a child to develop fee
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4. Find positive role models who yo
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You must accept that: 1. Chemical d
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Unfortunately, the tendency is for
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WHAT IS CODEPENDENCY? Codependency
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8. I am not aware of how I feel. I
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2. Feelings are not expressed openl
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4. Reintegration. Learning to be ok
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10. What are your fears, and how do
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Unfortunately, avoiding conflicts m
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12. Using force during conflicts. T
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PACK A SUITCASE 1. Pack basic cloth
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3. Process of how to accomplish tas
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Be Clear About What You Want Be Cle
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MAINTAIN THE PARENT ROLE 1. Be spec
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THE FAMILY MEETING The Family Meeti
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14. Have faith in your children so
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CRISIS RESOLUTION child is angry an
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eing bad (a new baby takes their pl
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TALKING TO CHILDREN F. Worries exce
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3. Communicate belief in the child
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PHYSICAL STRESS Whenever a person g
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COMMUNICATION Open and honest commu
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IS YOUR BEHAVIOR IN THE BEST INTERE
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GOAL SETTING 2. When you are succes
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RESOURCES 5. 6. 7. 8. 9. 10. Develo
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Professional Practice Forms Clinica
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Clinical Forms
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CASE FORMULATION If you are prepari
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3. Religion/spiritual beliefs 4. Cu
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TREATMENT PLAN Name: Date: DOB: SS#
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Presenting problem identified by cl
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2. Characteristics of Speech A. Des
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MENTAL STATUS EXAM Date: Name: INIT
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INITIAL CASE ASSESSMENT Name: Date
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INITIAL EVALUATION Person(s) presen
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BRIEF MENTAL HEALTH EVALUATION REVI
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Suicidal Ideation: __Yes No Homicid
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B. Give a brief history and develop
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L. Present interests, hobbies, and
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E. Do any of your children present
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S. What do expect to accomplish fro
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ADULT PSYCHOSOCIAL IDENTIFYING INFO
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DRUG AND ALCOHOL ABUSE 1. Any famil
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CHILD/ADOLESCENT PSYCHOSOCIAL IDENT
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Age when child first in home: Date
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Age How Long Reason Has child ever
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Did child have any specific learnin
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PARENT'S QUESTIONNAIRE Name of chil
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SELF-ASSESSMENT What is happening i
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ILLNESSES AND MEDICAL PROBLEMS Plea
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SUBSTANCE USE AND PSYCHOSOCIAL QUES
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4. Previous treatment experiences (
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CHEMICAL DEPENDENCY PSYCHOSOCIAL AS
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Problem #1: Problem #2: Problem #3:
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Mental Status: Mood Memory Processe
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OUTPATIENT TREATMENT PROGRESS REPOR
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Therapist Date Patient Outpatient T
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Fear of doing something uncontrolla
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2. Intervention and/or Teaching: 3.
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SOCIAL SECURITY EVALUATION MEDICAL
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DISABILITY STATUS Patient discharge
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Percepion Hallucinations: None, aud
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BRIEF LEVEL OF FUNCTIONING REVIEW F
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What are the treatment plan target
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OUTLINE FOR DIAGNOSTIC SUMMARY DIAG
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DISCHARGE SUMMARY NAME OF PATIENT:
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Bwsmess Forms 513
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PATIENT REGISTRATION (PLEASE PRINT)
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CONTRACT FOR SERVICES WITHOUT USING
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LIMITS ON PATIENT CONFIDENTIALITY W
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CONTRACT FOR GROUP THERAPY 1. As a
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CLIENT MESSAGES In-Chart Log Client
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REFERRAL FOR PSYCHOLOGICAL Evaluati
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RELEASE TO RETURN TO WORK OR SCHOOL
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DUTY TO WARN Although confidentiali
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RECEIPT RECEIPT Date of service: Na
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BALANCE STATEMENT Date Name Our rec
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8. Treatment ended with this therap
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QUALITY ASSURANCE REVIEW Patient Nu
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BIBLIOGRAPHY Ackerman, R., & Michae
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Bepko, C, & Krestan, J. A. (1985).
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Drabman, R. S., Spitalnick, R., & O
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Hackett, G., & Horan, J. J. (1980).
Page 1154:
Lazarus, R. (1966). Psychological s
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Othmer, E., & DeSouza C. (1985). A
Page 1162:
Washton, A. M. (1995). Psychotherap
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INDEX A Abuse neglect and child abu
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management scale 161 six stages of
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contract for group therapy 521 cont
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R Rational thinking realistic self-
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other ways 302 what are the myths o
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