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DSM > Week 2 > Flashcards

Week 2 Flashcards

1
Q

Prevention

Psychoeducation

A
  • Education around psychology
  • Learning key features Principles of recovery/treatment
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2
Q

Trends Today: Prevention

Life Management

A
  • Coaches to help ppl manage transitions New responsibilities etc Helping people live happy and fulfilling lives.
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3
Q

Trends Today: Prevention

Preventing needless self-disturbance

A
  • The worried well Ppl who are concerned for their health and safety because they worry
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4
Q

Trends Today: Prevention

Self-help

A
  • Becoming prominent
  • Spirituality is increasing
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5
Q

Trends Today: Prevention

  • What will happen with the titles of Counseling and Psychotherapy?
A
  • There will be a distinction without a difference No difference today
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6
Q

Trends Today: Prevention

What therapy will dominate and become more culturally sensitive And why?

A
  • Cognitive Behavioral Therapy
  • Goals will be cognitive/behavioral because it provides measurable objectives
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7
Q

Trends Today

What type of therapy will grow?

A
  • Brief therapy with an average of 8-12 sessions
  • (Average affected by skew of the people who only go once)
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8
Q

Trends Today

Trends Who will treatment be available to?

A
  • The treatable won’t be for those unlikely to respond to treatment
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9
Q

Trends Today

What types of assessments will become more common?

A
  • Computer driven assessment with lifestyle assessments
  • People are diagnosing themselves
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10
Q

Trends Today

Which fields of research will empathize the field profoundly and why will this help?

A
  • Molecular biology
  • Genetics
  • Counselors are marginalized for lack of medical knowledge
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11
Q

Trends Today

What type of Speciality services will increase?

A
  • Specific topics such as violence in the work place
  • Employee Assistance Programs
  • Wellness programs
  • Stress management
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12
Q

Trends Today

What is an Employee Assistance Program? (EAP)

A
  • Personnel who help employees with their problems
  • Assess them quickly and refer them
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13
Q

Trends Today

Why does the “solo act” have a limited future?

A
  • Systems of care
  • Need partnerships for referrals
  • Need to demonstrate quality
  • what we do is effective and works.
  • That we have the best knowledge of today and know that there are just some things we cannot solve today and communicate that)
  • Demonstrate that what we do is effective.
  • Communicate outcome data
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14
Q

Trends Today

What type of professional will focus be placed on?

A
  • Impaired professionals
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15
Q

Trends Today

1998 Impaired Professional Act

A
  • Very serious law; designed to protect the public
  • The inability or imminent inability for a health professional to practice the profession with reasonable skill or safety due to the use of mood altering drugs, chemical dependency or mental illness; must go to treatment or lose license.
  • **Has to impair performance**.
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16
Q

Trends Today

What might happen if you work with a colleague who is impaired and you ignore it?

A
  • You could lose your license You’d be protected if you were wrong
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17
Q

Trends Today

Counselor Choices

A
  • “Take the cash” – no insurance
  • “Make change” – adapt to insurance parameters on managed care
  • “Sell Shoes”
  • still must meet standards of profession
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18
Q

Clinical Director’s Point of View

(person in charge of the staff where clinicians work. Hires people, that person is a therapist)

A
  • Simple Philosophy
  • Provide quality of service- are paid to make a difference and if you cannot do that then step aside; the better the clinician, the better the client
  • Hire clinicians who have: you have to be able to fix whatever it is wrong.
    • Excellent clinical skills (people can do the job)
    • An understanding of modern health care
    • Excellent communication skills (be able to have an effective language ability)- written and oral.
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19
Q

Clinical Skills

Biopsychosocial History

A
  • from data to information- two different notions. Not really interested much in data, are interested in information
  • By translating data to information, he means that pieces of data may be things that end up pertaining to your client’s case -
    • Example: John Doe grows up in Tennessee in a rural community vs his wife, who grew up in Ann Arbor, MI
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20
Q

Clinical Skills

A
  • Biopsychosocial History
  • Integrated Summary
  • Treatment Planning
  • Intervening Effectively
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21
Q

Understanding Modern Health Care

A
  • Finances are part of the plan
  • ***Covered benefit vs. pre-authorization:
  • Referral Ethical issues
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22
Q

Understanding Modern Health Care

Covered Benefit

A
  • what insurance company say you have available to you
  • versus Pre-authorization (does not mean client can get all of what is covered
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23
Q

Understanding Modern Healthcare

Pre-Auth

A
  • determines how much
  • does not mean client can get all of what is covered
  • You will receive the amount out of the number that the pre-authorization/managed care folks will allow
  • not necessarily the max.
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24
Q

Understanding Modern Healthcare

Referral

A
  • (do not just tell person, all is controlled)
  • (you have to transfer clients that you cannot treat).
  • Refer people to clinicians or clinics to the places where they are best served
  • cannot just keep them because you need the business, etc.
  • Make sure whomever you refer your client to, that the client would still be covered under their insurance
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25
Q

Understanding Modern Healthcare

Ethical issues

A
  • (do not use up sessions in beginning, only so many are covered)
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26
Q

Communication Skills: The Clinical Record (the client’s “chart”)

Documents the findings

A
  • documentation of how client is on day one,
  • then what we did,
  • how things unfolded,
  • whether we made a positive impact today.
  • Must be written legibly
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27
Q

Communication Skills: The Clinical Record (the client’s “chart”)

Is a legal document

A
  • (if you must change an error on a document, you must draw a line through it so it can still be read, make the correction, initial and date the change; no white out!)
  • Write in a way that you would feel confident defending in court
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28
Q

Communication Skills

What does the clinical record need to reflect?

A
  • Clinical Intelligence and Therapeutic Skills
  • (JCAHO Standards– Joint Commission for Accreditation of Health Care Organizations)
  • *set all standards across health care, and accredits them. BCBS will only pay for accredited services.
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29
Q

Communication Skills

Clinical records need to be….

A
  • Coherent, logical, functional serves a helpful purpose and meaning of recording the clinical progress of the client while under my care.
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30
Q

Communication Skills

Represent the clinical case to payor

A
  • Use the correct/acceptable (clinical) language
  • Whatever you tell BCBS on the phone to get auths for treatment, you need to have the same thing demonstrated in that client’s case notes, or it’s FRAUD
  • Have a crisp treatment plan (There is a correct & acceptable language in our field that we must use.)
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31
Q

The Clinical Record Need Legal Document for…?

Interdisciplinary Communication

A
  • between different professionals serving the client
  • If the client must see a psychiatrist, and the psychiatrist needs your record
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32
Q

The Clinical Record: Need Legal Document for…?

Peer Review

A
  • (colleagues will review charts, committees will review them such as quality assurance, etc., a psychiatrist seeing your client may review it, etc.)
  • Used to be a bigger feature of clinical practice than it is today b/c of managed care
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33
Q

The Clinical Record: Need Legal Document for…?

Accountability

A
  • (to insurance companies, it documents the person was there)
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34
Q

The Clinical Record: Need Legal Document for…?

Guiding Treatment

A
  • keeps us on task for our goals and objectives)
  • tells us what’s working, what isn’t working, what we have changed/haven’t changed in our treatment
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35
Q

Clinical Record: Elements of Clinical Record

Consent for Treatment

A
  • (should not provide treatment to anyone until they sign consent for treatment)
  • (may contain reasons why their treatment might be cancelled
  • not putting forth any effort, wasting time, etc.)
  • (must always be written by an attorney)
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36
Q

Clinical Record: Elements of Clinical Record

Biopsychosocial History

A
  • Intake Info
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37
Q

Clinical Record: Elements of Clinical Record

Integrated Summary

A
  • (tail end of the biopsychosocial history)
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38
Q

Clinical Record: Elements of Clinical Record

Diagnosis

A
  • DSM
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39
Q

Clinical Record: Elements of Clinical Record

Master Treatment Plan

A
  • (what are we doing to treat it?)
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40
Q

Clinical Record: Elements of Clinical Record

Progress Notes

A
  • (occur after every session, outline)
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41
Q

Clinical Record: Elements of Clinical Record

Team Conference Notes

A
  • (analogous to our team presentations, talked about the case and got advice from one another)
42
Q

Clinical Record: Elements of Clinical Record

Discharge Summary

A
  • (happens for every person, even if the person never returns)
  • Summary of how they were when they left and why did they leave.
  • Presenting problem
  • Therapy provided
  • Progress that was made
  • Plan for discharge or no plan if the client is leaving on their own accord
43
Q

Clinical Record: Elements of Clinical Record

The Clinical Record Must Be:

A
  • Legible o Black or blue ink
  • Signed with credentials, date, and time (beginning and end time)
  • REMEMBER: “If it is not written down, it did not happen.”
  • You must document everything to make it legal.
44
Q

Interdisciplinary Communications

A
  • “If you know, it will show.”
45
Q

Interdisciplinary Communications

Poor documentation results in:

A
  • Denial of treatment to client o Rejection of payment in audit
46
Q

Interdisciplinary Communications

Vague/Abstract language must be avoided

A
  • “Depressed, doing well, making progress” are too vague.
  • Vague language is not acceptable.
  • Have something AEB. (ex: the patient’s progress is slow as evidenced by….)
  • “As evidenced by…” (AEB) → a little phrase that explains why
  • Describe symptoms, conditions, motivations concretely
47
Q

Regulatory Agencies

A
  • Public Health Department (can come by anytime) – No spoons in coffee area! No running wires!
  • Joint Commission for the Accreditation of Health Care Organizations - JCAHO (sets tone for country, “Gold Standard”, they accredit, paid by everyone because they set the standard) Come back every 3 years for charts, reports, to get re-accredited.
  • Payor (BCBS, HMOs, etc.–have their own standards)
  • The Clinic Administration (where you work – have their own regulations)
48
Q

Who can treat a client in an accredited clinic? *

(employer will grant these privileges)

A
  • A clinician with clinical privileges may do so independently
49
Q

Who can treat a client in an accredited clinic?

A clinician with clinical credentials may do so under supervision

A
  • (clinical credentials would be that a person has a degree, but doesn’t possess the expertise yet and will need supervision/training).
  • Supervisor is responsible for your actions.
50
Q

Who can treat a client in an accredited clinic? *

Privileges/credentials are granted by

A
  • the board of directors of your clinic or agency
51
Q

Who can treat a client in an accredited clinic? *

Clinical privileges are the authorization to deliver…

A
  • specific services independently
  • (eating disorder, adolescents, women, psychological testing, cognitive therapy, etc. all the services we offer)
52
Q

Who can treat a client in an accredited clinic? *

Most clinicians start with…?

A
  • credentials and move onto privileges in independent practices
53
Q

Who can treat a client in an accredited clinic? *

Requests for clinical privileges-

A
  • You can do it if you have something in your resume that shows that you are capable of doing this, course work, training, preparation, etc.
54
Q

Common Clinic Committees*

Continuous Quality Improvement [CQI]

A
  • (do studies all the time, Joint Commission also reviews, improving quality all the time)
  • where do we need to set the marker?
  • If we’re missing it, what do we have to do to fix it?
  • If we are missing it too often, what or who can we bring in to deliver better services.
55
Q

Common Clinic Committees*

Utilization review

A
  • are we providing the services that are needed?
  • Do we have the right personnel?
  • (Go through the charts and ask if all resources are being used, specializations – usurped by managed care now)
56
Q

Common Clinic Committees*

Safety

A
  • (involves plugs and wires – no heaters, etc.)
57
Q

Common Clinic Committees*

Infection Control

A
  • (how do we deal with infections, what are the rules for when a clinician is supposed to come to work after they have the flu)
58
Q

Common Clinic Committees*

Difference Clinical Privileging / Credentialing

A
  • committee of peers whose task it is to grant privileges for clinicians to practic
    • can be restricted or non-restricted
  • the credentials of the clinician must be proven to the committee
59
Q

Key problem areas:

A
  • Boundaries in therapeutic relationship: social, sexual, financial - Treatment outside competency: addictions, eating disorders, etc. - Violations of confidentiality: phone, room #, etc.
60
Q

Why do we Require Ethics Training?

A
  • Because the icons of ethics have been found wanting:
  • West Point cheating o Catholic Church clergy scandal
  • FBI investigative Laboratories
61
Q

Ethics Complaints in Social Work Practice

A
  • Poor practice = failure to meet accepted standards of care
  • Boundary violations = dual or sexual relationship
  • Conflict of interest = Therapist’s interest before that of client
  • Honesty = fraudulent, misleading and deceitful acts
  • Confidentiality
62
Q

Biopsychosocial History General

A
  • From data to Information o Medical condition/physiological functioning
  • Psychological functioning o Life and times of the client
  • ***Let things happen when doing this in the room w/ the client, but know when to move and when to stay***
63
Q

Clinical Skills: Biopsychosocial

After going through the History w/ the client, ask them what again?

A
  • why they made the choice to seek out therapy
  • (do this b/c at this point the client may be feeling more comfortable and able to be more open with you)
64
Q

Clinical Skills: Biopsychosocial

Integrated Summary

A
  • Summary of the Biopsychosocial history.
  • Pull things together in the context of the problem that brought the client in for help.
  • At the end of the summary, there will be a diagnosis.
  • List symptoms that the client has that goes with the disorders.
  • It must be 5 to 9.
65
Q

Clinical Skills: Biopsychosocial

Treatment Planning

A
  • What are we going to do to help this person?
66
Q

Clinical Skills: Biopsychosocial

Intervening Effectively

A
  • How do we communicate to this client that they came to talk to the right person? Therapeutic relationship is pivotal to outcome.
  • What will help them and what is supported in the research?
  • Every question is required by somebody (regulatory agency)
  • Must meet JCAHO standards
67
Q

Biopsychosocial History: Identifying Data:

Why is the Client’s physician info needed?

A
  • necessary to include for insurance
68
Q

Biopsychosocial History: Identifying Data

Source referral

A
  • part of business
  • Get back with the physician and thank them for the referral.
  • It lets them know the client came in and that we appreciate their business
69
Q

Biopsychosocial History: Identifying Data:

Presenting Problem

A
  • What brings you here?
  • If someone else sends, ask why?
  • What brings you to treatment now?
  • Something often precipitates their coming
    • wife threatens to leave, judge orders, etc.
    • If a judge sent them, write the problem first and write last the judge sent them so they will be covered by insurance
  • presentation is important!
70
Q

Biopsychosocial History: Substance Abuse Evaluation

A
  • Average Amount Used/Maximum Amount Used
    • must find out exact amount (ex. beer – was it a 12 oz, or a forty?)
  • Last use matters
    • are they sober enough to be able to recall valuable information
  • Level of drug problem is based on the level of consequences for use rather than amount
  • Pattern and frequency of use is important
71
Q

Biopsychosocial History: Substance Abuse Evaluation

Gleaning new info….

A
  • There is nothing wrong with changing diagnosis in light of new information
  • When you discover additional information, make a reference to the progress notes along with a date on the Biopsychosocial History
72
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Increased Tolerance

A
  • Breathalyzer score, comparison of events over time is requiring more of the chemical over time to get an effect
73
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Withdrawal Symptoms

A
  • What kind are they? Hangovers, blackouts?
74
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Loss of Control

A
  • Used more than intended, or for longer than intended. Include unsuccessful efforts to try and cut down and control use.
75
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Compulsion to Use

A
  • energy and time spent using substance
76
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Social Disruption

A
  • no longer engages in activities once enjoyed, now focused on substance
77
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Interference with Obligations and Social Disruption

A
  • How has it affected home life, family, school, work?
78
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Use Despite Contradications

A
  • known problems with work, school, family, drunk driving, yet use anyway
79
Q

Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior

Misc History

A
  • Craving
  • History of adverse reaction or overdose
80
Q

BPS history: II. Substance Abuse Evaluation

Prior Substance Abuse Treatment

A
  • When, where, how long, what kind of care & results
81
Q

BPS history: II. Substance Abuse Evaluation

Previous attempts to stop use and reasons for relapse

A
  • treatment plan needs to address these so they cannot happen again
  • Longest period of abstinence?
82
Q

BPS history: III. Psychological/Emotional History

Reported Symptoms of Primary Presenting Problem

A
  • Don’t wait for them to report all the symptoms
  • if you suspect a certain condition, run down the DSM-5 list of symptoms.
  • No matter what the condition is, it must be clinically significant -
  • there must be some psychological, social or occupational impairment.
  • Must use concrete criteria questions. Must write down DSM-5 criteria met as the “Reported Symptoms of Primary Diagnosis”
    • (i.e. Generalized Anxiety Disorder
  • client reports worrying about everything all the time → so this would be written down as “excessive worry” to match DSM-5 criteria
83
Q

BPS History:

III. Psychological/Emotional History

A
  • History of the condition
    • Age of onset, etc.
84
Q

BPS history: III. Psychological/Emotional History

History of related conditions

A
  • Alcohol use disorder, Opiate use, None, etc.
85
Q

BPS history: III. Psychological/Emotional History

Prior Psychological Treatment

A
  • Where, from when to when, reason and result. Include medications used, when last seen, etc.
86
Q

BPS history: III. Psychological/Emotional History

Therapist’s estimate of current danger to self or others

A
  • If you feel client is actively suicidal, you better be writing when they will be seeing a psychiatrist and not just that they are a danger to themselves
87
Q

BPS history: III. Psychological/Emotional History

Suicidal ideation

A
  • Suicide attempts, must know when, where and how.
  • If not current threat, then write “There is no current danger to self or others”
  • Current is an important protective word! If there is a threat write “There is a significant current danger to self or others” and then there must be a psychiatric evaluation within 24 hours, or you assume liability!
  • [Must refer; failure to do so is negligence.]
88
Q

BPS history: III. Psychological/Emotional History

Ask about…

A
  • History of psychological, physical or sexual abuse
  • Significant Life experiences (positive/negative)
  • Relatives have any troubles like the client is talking about? “Does anyone else in the family experience or have experienced any of the same struggles as you?”
  • Psychotherapy involvement (past/present) and response to it
  • Medications used (by history) – where, from/to, reason, result
  • “Have you been to counseling?” “How did that go?” “That must have been very disappointing for you? What happened?” Pay close attention to their prior experience!
89
Q

BPS history: IV. Childhood/Developmental History and Family of Origin

A
  • [Relationships with client and how they connect to the problems of the client.]
  • Description of Self
  • Description of father – What kind of relationship? Quality? Job?
  • Description of mother – What kind of relationship? Quality? Job?
  • Siblings – Birth order, relationship to patient and to parent
  • Ethnicity
  • Cultural influence – if raised in a different country…it may have an impact
  • Parent’s Discipline style
  • Family Activities
90
Q

BPS History: V. Social History

A
  • Education – What is patient’s highest level attained? If college, where did they study? If dropped out early, why?
  • Vocational Training – Gives person opportunity to feel they have achieved, if did not complete school, shows they do have special skills.
  • Military – Any problems while in military? When did you serve? What branch? Rank?
  • Quality of Relationship – Is the quality of the relationship moving up or down?
  • Description of Children – Get ages and such; different fathers, etc.
  • Current Occupation? Shift?
  • Employment History? Have they held down a job? How long?
91
Q

BPS History: V. Social History

Quality of relationship

A
  • Marriage? Age when married? How long? Separations? Describe your marriage Describe impact of condition on relationship
  • Previous marriage(s)
  • Children
  • Patient’s discipline style
  • Describe impact of condition on children
  • Description of present home life (relationships, activities, etc.)
  • Potential for family involvement in therapy: outcomes improve when family is involved.
92
Q

Biopsychosocial History

VI. Social Assessment

A
  • Religious Beliefs
  • basic needs
  • financial status
  • legal involvement
  • key findings from Physical Health Assessment
  • Recreation?
  • Peer group?
  • Social Skills?
93
Q

Biopsychosocial History: Social Assessment

Key Findings from Physical Health Assessment

A
  • Note if client has not seen a physician recently, may want to add as an objective to the Treatment Plan
  • If patient tells you they have chest pains, you should write in the assessment (and put into action), “Chest pains, agrees to make appointment and see doctor within next 3 days”
94
Q

Biopsychosocial History: Mental Status Evaluation

Need to evaluate every patient

A
  • look for themes
  • (altruistic, materialistic, idealistic, etc.)
95
Q

Biopsychosocial History: Mental Status Evaluation

General Behavior

A
  • Attire
  • facial expression
  • posture
  • gait
96
Q

Biopsychosocial History: Mental Status Evaluation

Stream of thought

A
  • How do they go from one thought to the next?
97
Q

Biopsychosocial History: Mental Status Evaluation

Emotional Tone and reaction: Affect

A
  • Indifferent, fearful, angry, euphoric etc
98
Q

Biopsychosocial History: Mental Status Evaluation

Mental trend/Content of thoughts: Perception

A
  • normal, auditory hallucination,
  • visual hallucination,
  • depersonalization (experience of being outside of yourself, observing yourself in the situation),
  • illusions,
  • derealization (the attribution of non-human factors to people, so others are things rather than people),
  • hypochondriasis
99
Q

Biopsychosocial History: Mental Status Evaluation

Cognition

A
  • obsessive and ruminative,
  • preoccupied,
  • self-depreciatory,
  • idiosyncratic,
  • stereotyped
100
Q

Biopsychosocial History: Mental Status Evaluation

Mental trend/Content of thoughts: Cognition Content

A
  • what are you obsessed about?
    • obsessions,
    • phobias, compulsive rituals,
    • religiosity, ideas of reference
    • belief that inanimate objects are communicating with you)
    • passivity feelings (feelings of non-person),
    • nihilistic (pessimism/vague),
    • delusions, self-derogatory delusions,
    • suicidal ideation,
    • bizarre ideas (thoughts of things that couldn’t happen) vs.
    • non-bizarre ideas (thoughts of things that realistically could have happened),
    • paranoid ideation (paranoid beliefs/thoughts)

DSM (7 decks)

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