GEHART CHAPTER 12 - CLINICAL ASSESSMENT Flashcards
WHY DO A CLINICAL ASSESSMENT?
- TO COORDINATE CARE WITH OTHER PROFESSIONALS/PROVIDERS.
- TO DECIDE HOW TO KEEP CLIENTS AND THE PUBLIC SAFE.
- DETERMINE NEED FOR REFERRALS AND ADDITIONAL SERVICES.
- IDENTIFY POTENTIAL COURSES OF TREATMENT
WHAT IS MY LENS THROUGH WHICH I SEE A CLIENT?
MY PERSONAL CULTURE, VALUES, HISTORY, BELIEFS, AND NORMS = MY WORLDVIEW.
WHY BECOME AWARE OF MY LENS?
IN ORDER TO SEE MY CLIENT MORE CLEARLY AND WITH LESS BIAS.
DIAGNOSIS AND GENDER
WOMEN CAN EASILY BE OVERPATHOLOGIZED.
MEN MAY BE UNDERDIAGNOSED IF THEY ARE HESITANT TO DISCUSS EMOTIONS.
CULTURAL FORMULATION
ENCOURAGING CO TO STEP BACK TO LEARN HOW A CL PROBLEMS ARE VIEWED IN THE CONTEXT OF THEIR CULTURE. ALSO CONSIDER RELEVANT SOCIOPOLITICAL AND SOCIAL JUSTICE ISSUES
SYSTEMIC PERSPECTIVE ON DIAGNOSIS
A DX DESCRIBES THE BEHAVIORS THAT A PERSON HAS ADOPTED TO MAINTAIN BALANCE IN CURRENT THEIR SYSTEM/RELATIONSHIPS.
POSTMODERN PERSPECTIVE ON DIAGNOSIS
SKEPTICAL. CLIENTS MAY INTEGRATE DX INTO THEIR IDENTITY WHICH CAN CREATE A SELF FULFILLING PROPHECY.
GENERAL FAMILY THERAPY APPROACH TO DIAGNOSIS
DX IS CONSIDERED TO BE JUST ONE VOICE IN A CONVERSATION. SOME CLIENTS WILL SEE DX AS HELPFUL IN TREATMENT, OTHERS HURTFUL. THE SYMPTOMS, FEELINGS, AND BEHAVIORS THAT QUALIFY A PERSON FOR A DX ARE SUBJECT TO CHANGE BASED ON THE CHANGES MADE IN THEIR RELATIONSHIPS/SYSTEMS
RECOVERY MODEL
HELPING CLIENTS LEAD MEANINGFUL LIVES INSTEAD OF REDUCING THEIR SYMPTOMS OF A MH DX.
EMPHASIZES PSYCHOSOCIAL FUNCTIONING, DEEMPHASIZES DIAGNOSTIC LABELING
MENTAL HEALTH RECOVERY-ORIENTED CARE
*SELF-DIRECTION
CL EXERCISE CHOICE OVER THEIR PATH TO RECOVERY/TREATMENT.
MENTAL HEALTH RECOVERY-ORIENTED CARE
*INDIVIDUALIZED/PERSON-CENTERED
PATHS TO RECOVERY ARE BASED ON THE INDIVIDUAL’S UNIQUE STRENGTHS, RESILIENCIES, PREFERENCES, EXPERIENCES, AND CULTURAL BACKGROUND
MENTAL HEALTH RECOVERY-ORIENTED CARE
*EMPOWERMENT
CL HAVE AUTHORITY TO CHOOSE FROM OPTIONS AND PARTICIPATE IN MAKING DECISIONS.
MENTAL HEALTH RECOVERY-ORIENTED CARE
*HOLISTIC
ENCOMPASSING ALL ASPECTS OF LIFE: MIND, BODY, SPIRIT, COMMUNITY
MENTAL HEALTH RECOVERY-ORIENTED CARE
*NONLINEAR
RECOVERY IS NOT A STEP BY STEP PROCESS BUT RATHER ONGOING PROCESS WITH GROWTH AND SETBACKS
MENTAL HEALTH RECOVERY-ORIENTED CARE
*STRENGTHS BASED
FOCUSES ON VALUING AND BUILDING STRENGTHS, ABILITIES, AND RESILIENCE.
MENTAL HEALTH RECOVERY-ORIENTED CARE
*PEER SUPPORT
CL ARE ENCOURAGED TO ENGAGE WITH OTHER CLIENTS IN PURSUING RECOVERY
MENTAL HEALTH RECOVERY-ORIENTED CARE
*RESPECT
FOR RECOVERY TO OCCUR, CONSUMERS NEED TO EXPERIENCE RESPECT FROM PROFESSIONALS, COMMUNITY, AND OTHER SYSTEMS
MENTAL HEALTH RECOVERY-ORIENTED CARE
*RESPONSIBILITY
CL ARE PERSONALLY RESPONSIBLE FOR THEIR RECOVERY AND SELF-CARE
MENTAL HEALTH RECOVERY-ORIENTED CARE
*HOPE
RECOVERY REQUIRES A BELIEF IN THE SELF AND A WILLINGNESS TO PERSEVERE THROUGH CHALLENGES.
PARITY AND NONPARITY DX
PARITY - TYPICALLY INCLUDE SEVERE MH DISORDERS AND MUST BE PRIMARY DX. INSURANCE COMPANIES MUST PAY FOR IT.
ETIOLOGY
THE CAUSE OR ORIGIN OF A DISEASE
INTERNALIZING DISORDERS
MOSTLY EMOTIONAL AND COGNITIVE SYMPTOMS THAT OCCUR WITHIN THE PERSON
EXTERNALIZING DISORDERS
MORE BEHAVIORAL AND EXTERNAL SYMPTOMS
ICD
INTERNATIONAL CLASSIFICATION OF DISEASES
AXIS I
CLINICAL DISORDERS THAT ARE THE FOCUS OF TREATMENT, PRIMARY REASON FOR VISIT LISTED FIRST, INCLUDING DEVELOPMENTAL AND LEARNING DISORDERS
AXIS II
UNDERLYING OR PERVASIVE CONDITIONS, INCLUDING PERSONALITY DISORDERS, DEFENSIVE MECHANISMS, AND MENTAL RETARDATION
AXIS III
MEDICAL CONDITIONS AND DISORDERS
AXIS IV
PSYCHOSOCIAL STRESSORS AND ENVIRONMENTAL CONDITIONS THAT MAY BE CONTRIBUTING TO A CONDITION AND/OR TREATMENT. E.G., ECONOMIC OR HOUSING PROBLEMS, PROBLEMS WITH PRIMARY SUPPORT SYSTEM (FAMILY, PARTNER, ETC.)
AXIS V
GLOBAL ASSESSMENT OF FUNCTIONIN (GAF)
- 70 AND ABOVE - SHOWS ADAPTIVE COPING AND GREATER MH
- 60-69 - MILD SYMPTOMS (INSURANCE TYPICALLY REQUIRES 69 OR BELOW)
- 50-59 - MODERATE SYMPTOMS
- 40-49 - SEVERE SYSTEMS
- 39 AND BELOW - SIGNIFICANT IMPAIRMENT THAT GENERALLY REQUIRES HOSPITALIZATION AND INTENSIVE TREATMENT.
SUBTYPES
MUTUALLY EXCLUSIVE SUBGROUPS WITHIN THE DIAGNOSTIC CATEGORY
SPECIFIER
USED TO NOTE INFORMATION ABOUT A CL’S CONDITION THAT MAY BE USEFUL FOR TX DECISIONS, WRITTEN AFTER THE NAME OF THE DIAGNOSIS ON THE DX LINE.
DIMENSIONAL APPROACH
VARIATION OF INTENSITY ON A GIVEN SYMPTOM OR DIMENSION
NOS
NOT OTHERWISE SPECIFIED - NO LONGER BEING USED
NEC
NOT-ELSEWHERE-CLASSIFIED WHICH MAY BE AN “OTHER SPECIFIED DISORDER” OR “UNSPECIFIED DISORDER.”
OTHER SPECIFIED DISORDER
ALLOWS CO TO DOCUMENT THE SPECIFIC REASON A CL DOES NOT MEET THE CRITERIA FOR A SPECIFIC DX.
UNSPECIFIED DISORDERS
USED WHEN A CL EXPERIENCES SIGNIFICANT CLINICAL DISTRESS BUT DOES NOT MEET THE CRITERIA FOR THE DISORDER. E.G., IN THE ER.
WHODAS 2.0
WORLD HEALTH ORGANIZATION DISABILITY ASSESSMENT SCHEDULE 2.0
-USED TO ASSESS DISABILITY IN THE DOMAINS OF COMMUNICATION, GETTING AROUND, SELF-CARE, GETTING ALONG WITH PEOPLE, LIFE ACTIVITIES, AND PARTICIPATION IN SOCIETY.
SYSTEMIC APPROACH TO THE MSE
USING THE SYSTEMIC PROBLEM ASSESSMENT INVOLVES TRACING INTERACTIONS FROM INITIAL HOMEOSTASIS TO ESCALATION OF SYMPTOMS (POSITIVE FEEDBACK LOOP) UNTIL THE SYSTEM RETURNS TO NORMAL OR HOMEOSTASIS.
POSTMODERN APPROACH TO THE MSE
HONORING A CL’S DESCRIPTION AND PERCEPTION OF A PROBLEM
MAPPING THE INFLUENCE OF A PROBLEM
CROSS-CUTTING SYMPTOM MEASURES
MEASURES THAT ALLOW CO TO QUICKLY IDENTIFY KEY SYMPTOMS THAT MAY OCCUR ACROSS VARIOUS DX. TWO TIER SYSTEM.
LEVEL 1 - BROAD ASSESSMENT FOR IDENTIFYING POTENTIAL AREAS OF CONCERN
LEVEL 2 - ASSESS IN GREATER DETAIL AREAS IDENTIFIED IN LEVEL 1.
MAKING A DIAGNOSIS
RULE OUT SUBSTANCE USE
RULE OUT MEDICATIONS AND MEDICAL CONDITIONS
TRAUMA
CO CONSIDERS ALL FORMS OF INFORMATION - CL REPORT, CO OBSERVATION, FAMILY DYNAMICS, GENDER AND CULTURAL FORCES, ETHICAL ISSUES, (LABELING) AND USE THEIR BEST JUDGEMENT.
