Therapist's Guide to Clinical Intervention - Sigmund Freud

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Mental Status: Mood Affect Memory Processes Hallucinations Judgment Insight Impulse Control normal depressed elevated euphoric angry irritable anxious normal broad restricted blunted flat inappropriate liable intact short-term problems long-term problems normal blocking loose associations confabulations flight of ideas ideas of reference grandiosity paranoia obsession preseverations depersonalization suicidal ideation homicidal ideation none auditory visual olfactory gustatory somatic tactile good fair poor good fair poor good fair poor Client's Attitude Toward Treatment: accepting neutral resistant Communications: talkative satisfactory open guarded answers questions only other Therapist Date Chemical Dependency Assessment 181
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Therapist's Guide to Clinical Inter
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Therapist's Guide to Clinical Inter
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CONTENTS Introduction xvii Level of
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Chapter 2 ASSESSING SPECIAL CIRCUMS
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Evaluation and Disposition Consider
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Ten Ways of Responding to Aggressio
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Low Self-Esteem 330 The Self-Esteem
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Couple's Conflict: Rules for Fighti
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Insured/Responsible Party Informati
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INTRODUCTION THIS second edition, l
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Level of Patient Care and Practice
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Levels of Functioning and Associate
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The Treatment Plan formulation serv
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*HIPAA: Health Insurance Portabilit
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COMMON AXIS 1 AND AXIS 2 DIAGNOSES
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Treatment Focus and Objectives 4. D
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Dual Diagnosis (developmentally dis
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E. Proceed in treatment plan with t
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In cases where ADHD is suspected, f
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C. Role-model and practice communic
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Additional Considerations D. Use ve
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Additional Considerations 3. Excess
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Additional Considerations B. Teach
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EATING DISORDER (EDO) Due to the ov
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G. Encourage appropriate separation
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Additional Considerations 13. Self-
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Obsession with Weight Obesity and S
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IDENTITY DISORDER This disorder is
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CHILDREN When working with children
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Freud's constructs of psychosocial
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DEMENTIA D drug interaction E emoti
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7. Risk for Injury A. Assess 1. Psy
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D. Systemic illness 1. Substance in
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shaping of a new identity integrati
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3. Setting limits and boundaries 4.
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LIST OF SYMPTOMS LEADING TO RELAPSE
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44 Common Drugs of Abuse (Continued
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B. If this has been an ongoing case
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how to respond to the various side
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1. Diagnosis A. Schizophrenia B. Br
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Goals Treatment Focus and Objective
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E. Evaluate impaired social interac
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8. Weight loss or gain 9. Priapism
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MANIA Goals 1. Provide safe environ
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J. Identify and focus on positive a
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2. Culture may influence under diag
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B. Moderate to severe depression: w
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Treatment Focus 1. Assess for Refer
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E Irrational Beliefs 1. Identify fa
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It is evident that unless cognitive
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SOMATOFORM DISORDERS The central fe
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B. Encourage independent fulfillmen
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. Scholarly reading c. Independent
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DISSOCIATIVE DISORDERS 2. Somatizat
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SEXUAL DISORDERS 5. Identity Distur
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the intensity of the stressor. Inst
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Medication might be utilized as a s
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not often present for treatment of
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PERSONALITY DISORDERS B. Facilitate
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B. Facilitate identification of fee
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I. Facilitate the use of thought st
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7. Overly Sensitive A. Facilitate i
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Treatment Focus and Objectives 5. M
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Goals Treatment Focus and Objective
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3. Dramatized Social Interaction A.
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3. Increase awareness for intensity
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PHYSICAL FACTORS AFFECTING PSYCHOLO
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Medical Causes of Psychiatric Illne
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This page intentionally left blank
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Outline of the Interview 1. Succinc
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STRUCTURED INTERVIEW FOR DEPRESSION
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Subjective Patient Review of Self A
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6. social support (lack of support
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118 2. Assessing Special Circumstan
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Risk History Explain any significan
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CYCLE OF PHOBIC ANXIETY Physiologic
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5. Inadequate Coping A. Consequence
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TRANSPORTATION Assess ability to ef
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CRISIS EVALUATION The crisis evalua
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4. What was the person feeling and
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Page 372: 156 2. Assessing Special Circumstan
Page 380: PAIN IDENTIFICATION CHART Name Date
Page 388: 7. Positive feedback and reinforcem
Page 400: 3. Feeling high after vomiting or s
Page 404: EATING DISORDER EVALUATION: BULIMIA
Page 408: ADULT ADD SCREENING 174 2. Assessin
Page 420: B. Social (Description of peer asso
Page 426: S.O. Relationships and History of C
Page 430: WITHDRAWAL SYMPTOMS CHECKLIST Ratin
Page 434: SPOUSAL/PARTNER ABUSE The victim of
Page 438: L. Centrality of partner M. Depress
Page 442: A General Systems Model of Domestic
Page 446: 6. Victim symptom presentation A. D
Page 450: OBJECTIVES 1. Enhance experience of
Page 454: General Symptoms of Possible Child
Page 458: The purpose of the Bonding Study is
Page 462: H. Parent-Child Interaction 1. How
Page 466: CHILD'S OWN SCENARIOS These are exp
Page 470: 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).
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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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Therapist's Guide to Clinical Intervention - Sigmund Freud

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