Week 2 Flashcards
Prevention
Psychoeducation
- Education around psychology
- Learning key features Principles of recovery/treatment
Trends Today: Prevention
Life Management
- Coaches to help ppl manage transitions New responsibilities etc Helping people live happy and fulfilling lives.
Trends Today: Prevention
Preventing needless self-disturbance
- The worried well Ppl who are concerned for their health and safety because they worry
Trends Today: Prevention
Self-help
- Becoming prominent
- Spirituality is increasing
Trends Today: Prevention
- What will happen with the titles of Counseling and Psychotherapy?
- There will be a distinction without a difference No difference today
Trends Today: Prevention
What therapy will dominate and become more culturally sensitive And why?
- Cognitive Behavioral Therapy
- Goals will be cognitive/behavioral because it provides measurable objectives
Trends Today
What type of therapy will grow?
- Brief therapy with an average of 8-12 sessions
- (Average affected by skew of the people who only go once)
Trends Today
Trends Who will treatment be available to?
- The treatable won’t be for those unlikely to respond to treatment
Trends Today
What types of assessments will become more common?
- Computer driven assessment with lifestyle assessments
- People are diagnosing themselves
Trends Today
Which fields of research will empathize the field profoundly and why will this help?
- Molecular biology
- Genetics
- Counselors are marginalized for lack of medical knowledge
Trends Today
What type of Speciality services will increase?
- Specific topics such as violence in the work place
- Employee Assistance Programs
- Wellness programs
- Stress management
Trends Today
What is an Employee Assistance Program? (EAP)
- Personnel who help employees with their problems
- Assess them quickly and refer them
Trends Today
Why does the “solo act” have a limited future?
- 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
Trends Today
What type of professional will focus be placed on?
- Impaired professionals
Trends Today
1998 Impaired Professional Act
- 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**.
Trends Today
What might happen if you work with a colleague who is impaired and you ignore it?
- You could lose your license You’d be protected if you were wrong
Trends Today
Counselor Choices
- “Take the cash” – no insurance
- “Make change” – adapt to insurance parameters on managed care
- “Sell Shoes”
- still must meet standards of profession
Clinical Director’s Point of View
(person in charge of the staff where clinicians work. Hires people, that person is a therapist)
- 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.
Clinical Skills
Biopsychosocial History
- 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
Clinical Skills
- Biopsychosocial History
- Integrated Summary
- Treatment Planning
- Intervening Effectively
Understanding Modern Health Care
- Finances are part of the plan
- ***Covered benefit vs. pre-authorization:
- Referral Ethical issues
Understanding Modern Health Care
Covered Benefit
- what insurance company say you have available to you
- versus Pre-authorization (does not mean client can get all of what is covered
Understanding Modern Healthcare
Pre-Auth
- 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.
Understanding Modern Healthcare
Referral
- (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
Understanding Modern Healthcare
Ethical issues
- (do not use up sessions in beginning, only so many are covered)
Communication Skills: The Clinical Record (the client’s “chart”)
Documents the findings
- 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
Communication Skills: The Clinical Record (the client’s “chart”)
Is a legal document
- (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
Communication Skills
What does the clinical record need to reflect?
- 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.
Communication Skills
Clinical records need to be….
- Coherent, logical, functional serves a helpful purpose and meaning of recording the clinical progress of the client while under my care.
Communication Skills
Represent the clinical case to payor
- 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.)
The Clinical Record Need Legal Document for…?
Interdisciplinary Communication
- between different professionals serving the client
- If the client must see a psychiatrist, and the psychiatrist needs your record
The Clinical Record: Need Legal Document for…?
Peer Review
- (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
The Clinical Record: Need Legal Document for…?
Accountability
- (to insurance companies, it documents the person was there)
The Clinical Record: Need Legal Document for…?
Guiding Treatment
- 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
Clinical Record: Elements of Clinical Record
Consent for Treatment
- (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)
Clinical Record: Elements of Clinical Record
Biopsychosocial History
- Intake Info
Clinical Record: Elements of Clinical Record
Integrated Summary
- (tail end of the biopsychosocial history)
Clinical Record: Elements of Clinical Record
Diagnosis
- DSM
Clinical Record: Elements of Clinical Record
Master Treatment Plan
- (what are we doing to treat it?)
Clinical Record: Elements of Clinical Record
Progress Notes
- (occur after every session, outline)
Clinical Record: Elements of Clinical Record
Team Conference Notes
- (analogous to our team presentations, talked about the case and got advice from one another)
Clinical Record: Elements of Clinical Record
Discharge Summary
- (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
Clinical Record: Elements of Clinical Record
The Clinical Record Must Be:
- 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.
Interdisciplinary Communications
- “If you know, it will show.”
Interdisciplinary Communications
Poor documentation results in:
- Denial of treatment to client o Rejection of payment in audit
Interdisciplinary Communications
Vague/Abstract language must be avoided
- “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
Regulatory Agencies
- 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)
Who can treat a client in an accredited clinic? *
(employer will grant these privileges)
- A clinician with clinical privileges may do so independently
Who can treat a client in an accredited clinic?
A clinician with clinical credentials may do so under supervision
- (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.
Who can treat a client in an accredited clinic? *
Privileges/credentials are granted by
- the board of directors of your clinic or agency
Who can treat a client in an accredited clinic? *
Clinical privileges are the authorization to deliver…
- specific services independently
- (eating disorder, adolescents, women, psychological testing, cognitive therapy, etc. all the services we offer)
Who can treat a client in an accredited clinic? *
Most clinicians start with…?
- credentials and move onto privileges in independent practices
Who can treat a client in an accredited clinic? *
Requests for clinical privileges-
- 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.
Common Clinic Committees*
Continuous Quality Improvement [CQI]
- (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.
Common Clinic Committees*
Utilization review
- 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)
Common Clinic Committees*
Safety
- (involves plugs and wires – no heaters, etc.)
Common Clinic Committees*
Infection Control
- (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)
Common Clinic Committees*
Difference Clinical Privileging / Credentialing
- 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
Key problem areas:
- Boundaries in therapeutic relationship: social, sexual, financial - Treatment outside competency: addictions, eating disorders, etc. - Violations of confidentiality: phone, room #, etc.
Why do we Require Ethics Training?
- Because the icons of ethics have been found wanting:
- West Point cheating o Catholic Church clergy scandal
- FBI investigative Laboratories
Ethics Complaints in Social Work Practice
- 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
Biopsychosocial History General
- 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***
Clinical Skills: Biopsychosocial
After going through the History w/ the client, ask them what again?
- 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)
Clinical Skills: Biopsychosocial
Integrated Summary
- 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.
Clinical Skills: Biopsychosocial
Treatment Planning
- What are we going to do to help this person?
Clinical Skills: Biopsychosocial
Intervening Effectively
- 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
Biopsychosocial History: Identifying Data:
Why is the Client’s physician info needed?
- necessary to include for insurance
Biopsychosocial History: Identifying Data
Source referral
- 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
Biopsychosocial History: Identifying Data:
Presenting Problem
- 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!
Biopsychosocial History: Substance Abuse Evaluation
- 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
Biopsychosocial History: Substance Abuse Evaluation
Gleaning new info….
- 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
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Increased Tolerance
- Breathalyzer score, comparison of events over time is requiring more of the chemical over time to get an effect
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Withdrawal Symptoms
- What kind are they? Hangovers, blackouts?
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Loss of Control
- Used more than intended, or for longer than intended. Include unsuccessful efforts to try and cut down and control use.
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Compulsion to Use
- energy and time spent using substance
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Social Disruption
- no longer engages in activities once enjoyed, now focused on substance
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Interference with Obligations and Social Disruption
- How has it affected home life, family, school, work?
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Use Despite Contradications
- known problems with work, school, family, drunk driving, yet use anyway
Bio-History: Substance Abuse: DSMIV Evaluation of Dependency: AEB Behavior
Misc History
- Craving
- History of adverse reaction or overdose
BPS history: II. Substance Abuse Evaluation
Prior Substance Abuse Treatment
- When, where, how long, what kind of care & results
BPS history: II. Substance Abuse Evaluation
Previous attempts to stop use and reasons for relapse
- treatment plan needs to address these so they cannot happen again
- Longest period of abstinence?
BPS history: III. Psychological/Emotional History
Reported Symptoms of Primary Presenting Problem
- 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
BPS History:
III. Psychological/Emotional History
- History of the condition
- Age of onset, etc.
BPS history: III. Psychological/Emotional History
History of related conditions
- Alcohol use disorder, Opiate use, None, etc.
BPS history: III. Psychological/Emotional History
Prior Psychological Treatment
- Where, from when to when, reason and result. Include medications used, when last seen, etc.
BPS history: III. Psychological/Emotional History
Therapist’s estimate of current danger to self or others
- 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
BPS history: III. Psychological/Emotional History
Suicidal ideation
- 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.]
BPS history: III. Psychological/Emotional History
Ask about…
- 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!
BPS history: IV. Childhood/Developmental History and Family of Origin
- [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
BPS History: V. Social History
- 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?
BPS History: V. Social History
Quality of relationship
- 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.
Biopsychosocial History
VI. Social Assessment
- Religious Beliefs
- basic needs
- financial status
- legal involvement
- key findings from Physical Health Assessment
- Recreation?
- Peer group?
- Social Skills?
Biopsychosocial History: Social Assessment
Key Findings from Physical Health Assessment
- 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”
Biopsychosocial History: Mental Status Evaluation
Need to evaluate every patient
- look for themes
- (altruistic, materialistic, idealistic, etc.)
Biopsychosocial History: Mental Status Evaluation
General Behavior
- Attire
- facial expression
- posture
- gait
Biopsychosocial History: Mental Status Evaluation
Stream of thought
- How do they go from one thought to the next?
Biopsychosocial History: Mental Status Evaluation
Emotional Tone and reaction: Affect
- Indifferent, fearful, angry, euphoric etc
Biopsychosocial History: Mental Status Evaluation
Mental trend/Content of thoughts: Perception
- 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
Biopsychosocial History: Mental Status Evaluation
Cognition
- obsessive and ruminative,
- preoccupied,
- self-depreciatory,
- idiosyncratic,
- stereotyped
Biopsychosocial History: Mental Status Evaluation
Mental trend/Content of thoughts: Cognition Content
- 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)
