Utilize a current or past clinical case, develop a treatment plan using the six-step process discussed in class.

Evidence-Based Treatment Plan (5 pages):

Utilize a current or past clinical case, develop a treatment plan using the six-step process discussed in class.

The treatment plan must include the following:

Brief case history (if you’re not using a vignette; 1-2 paragraphs will be sufficient)

Primary & secondary problems

DSM-5 Diagnosis

Long-term goals

Short-term (measurable) objectives

Specific therapeutic interventions paired with objectives

Requirements: 5 pages

The Department of Counseling – Community Family Life Center Treatment Plan Example Page 1 of 2 Revised: 12/8/2009 Treatment Plan Example TREATMENT PLANNING  Introduction – Treatment planning can be defined as the process in which the counselor and client identify and rank problems needing resolution, establish agreed upon immediate and long-term goals, and decide on the treatment methods and resources to be used.  Problem Selection – Determine the most significant problems/challenges on which to focus the treatment process. Selected primary and/or secondary problems/challenges can help focus the counseling process.  Problem Definition – Many problems/challenges present with certain characteristics or patterns. These patterns/symptoms may be identified in the DSM-IV-TR, ICD or other behaviorally defined methods.  Goal Development – The next step is to develop a broad goal for resolving the target problem or challenge. This goal can be stated as a global, long-term goal that indicates positive growth.  Objectives – In contrast to long-term goals, objectives are behaviorally accountable statements, so that it is clear that the client has achieved the stated objective.  Interventions – Interventions are the clinician’s actions that are designed to help the client reach/complete the objectives. Interventions are selected based on the client’s needs and the treatment providers’ skills.  Diagnosis – An appropriate diagnosis is based on the client’s complete clinical presentation and evaluation. This is often compared with the behavioral, cognitive, emotional, and interpersonal symptoms/challenges that the client presents with to the criteria described in the DSM-IV-TR or ICD.

The Department of Counseling – Community Family Life Center Treatment Plan Example Page 2 of 2 Revised: 12/8/2009 EXAMPLE Client One- presents with Depression, Post Traumatic Stress Disorder (PTSD) I. Problem Definition A. Depression: 1. Client presents with poor concentration and indecisiveness. 2. Complains about poor appetite and difficulty sleeping. 3. Children being placed in CPS custody. B. Post Traumatic Stress Disorder: 1. Client presents with hypervigilance. 2. Client presents with signs of physical abuse. Indicates abusive relationship history in excess of 3 years. 3. Client also complains of poor sleep habits. 4. Client also presents with exaggerated startle responses at intermittent times during interview. II. Long-term Goals A. Depression: 1. Develop healthy cognitive patterns and beliefs about self and increase self-esteem. B. PTSD: 1. Replace self defeating beliefs and behavior patterns which serve to foster and maintain abusive relationship(s) with self affirming belief and behavior patterns. 2. Reduce the negative impact that history of physical abuse has had on many aspects of client’s life and move towards healthy relationships. III. Objectives A. Depression: 1. Describe current and past experiences with depression, including prior attempts to resolve it. 2. Complete psychological testing (using BDI) to assess the depth of the depression, for possible referral for anti-depressants and suicide prevention measures. B. PTSD: 1. Describe history and nature of PTSD symptoms. 2. Describe traumatic event as mush as possible. 3. Verbalize an accurate understanding of PTSD and how it develops. 4. Verbalize an understanding of the rationale for treatment. IV. Interventions A. Depression: 1. B. PTSD: 1. V. Diagnosis Axis I: PTSD, Depression Axis II: Diagnosis Deferred Axis III: Bruising Axis IV: Abusive Relationship, Legal issues with CPS and removal of 2 children ages; 2 and 5.

Case 1: Anna Case Study Details: Anna is a 28-year-old Caucasian woman who has struggled with alcohol use for most of her teenage and young adult life. She began drinking in high school, at age 15, and dropped out of college partway through her first year because she was missing so many classes due to alcohol use. She has attempted to go back to school twice since then but has been unsuccessful each time due to relapses. Anna reports multiple attempts to stop drinking, but has only been able to maintain sobriety for 2-4 weeks at a time. Whenever she tries to stop drinking, she gets nauseous, shaky, and disoriented. Within the last 4 months, she has withdrawn from her friends, feels sad almost every day, and has frequent suicidal ideation. Her appetite has decreased, but her alcohol use has continued to increase, and she is currently consuming approximately half a “fifth” of vodka per day. She has frequent arguments with her parents, who are now threatening to cut her off financially because she spends most of her rent money on alcohol. She “can’t stop thinking about my next drink,” and reports feelings of guilt and worthlessness over being unable to stop drinking. Symptoms: ¥ Alcohol Use ¥ Depression ¥ Guilt ¥ Irritability ¥ Loss of Interest ¥ Substance Abuse ¥ Suicidal thoughts

Case 2: Jen Case Study Details: Jen is a 29 year-old woman who presents to your clinic in distress. In the interview she fidgets and has a hard time sitting still. She opens up by telling you she is about to be fired from her job. In addition, she tearfully tells you that she is in a major fight with her husband of 1 year because he is ready to have children but she fears that she is “too disorganized to be a good mother.” As you break down some of the processes that have led to her current crises, you learn that she has a hard time with time management and tends to be disorganized. She chronically misplaces everyday objects like her keys and runs late to appointments. Although she wants her work to be perfect, she is prone to making careless mistakes. The struggle for perfection makes starting a new task feel very stressful, leading her to procrastinate starting in the first place. As a consequence, she has recently received a number of warnings from her boss related to missing deadlines for assignments and errors in her work, which has led to her acute fear of being fired. As her performance at work has plummeted and she has grown increasingly anxious and doubting of herself, she has grown more pessimistic about starting a family. You learn that she received extra time for test taking in school as a child but never had any formal neuropsychological testing. With Jen’s permission, you conduct additional structured assessments, including collecting collateral information from her fiancé, and conclude that she has adult ADHD. Symptoms ¥ Anxiety ¥ Concentration Difficulties ¥ Impulsivity ¥ Worry

Case 3: Victor Case Study Details: Victor is a 27-year-old man who comes to you for help at the urging of his fiancée. He was an infantryman with a local Marine Reserve unit who was honorably discharged in 2014 after serving two tours of duty in Iraq. His fiancé has told him he has “not been the same” since his second tour of duty and it is impacting their relationship. Although he offers few details, upon questioning he reports that he has significant difficulty sleeping, that he “sleeps with one eye open” and, on the occasions when he falls into a deeper sleep, he has nightmares. He endorses experiencing several traumatic events during his second tour, but is unwilling to provide specific details – he tells you he has never spoken with anyone about them and he is not sure he ever will. He spends much of his time alone because he feels irritable and doesn’t want to snap at people. He reports to you that he finds it difficult to perform his duties as a security guard because it is boring and gives him too much time to think. At the same time, he is easily startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty and at home. He describes having intrusive memories about his traumatic experiences on a daily basis but he declines to share any details. He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he does not want to remember. Symptoms: ¥ Hypervigilance ¥ Intrusive Thoughts ¥ Irritability ¥ Loss of Interest ¥ Sleep Difficulties ¥ Trauma

Case 4: Mike Caste Study Details: Mike is a 20 year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he’ll “probably flunk out.” He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. Mike has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college. You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him – he assumes they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors. After conducting your assessment, you give the patient feedback that you believe he has social anxiety disorder, which should be the primary treatment target. You explain that you see his fear of negative evaluation, and his thoughts and behaviors surrounding social situations, as driving his increasing sense of hopelessness, isolation, and worthlessness. Symptoms: ¥ Anxiety ¥ Depression ¥ Ruminations ¥ Social Anxiety

Case 5: Richard Case Study Details: Richard is a 62-year-old single man who says that his substance dependence and his bipolar disorder both emerged in his late teens. He says that he started to drink to “feel better” when his episodes of depression made it hard for him to interact with his peers. He also states that alcohol and cocaine are a natural part of his manic episodes. He also notes that coming off the cocaine and binge drinking contribute to low mood, but he has not responded well to referrals to AA and past inpatient stays have led to only temporary abstinence. Yet, Richard is now trying to forge a closer relationship to his adult children, and he says he is especially motivated to get a better handle on both his bipolar disorder and his substance use. He has been more compliant with his mood stabilizing and antidepressant medication, and his psychiatrist would like his dual diagnoses addressed with psychotherapy. Symptoms: ¥ Alcohol Use ¥ Depression ¥ Elevated Mood ¥ Impulsivity ¥ Mania/Hypomania ¥ Mood Cycles ¥ Substance Abuse

Evidence-Based Practice TreatmentModule 1 Maria Cristina Samaco-Zamora, Ph.D.

Topics to be covered¥Overview of Evidence-Based Practice (EBP) ¥Empirically Supported Treatments (EST) ¥Advantages & Disadvantages of Using EST

OVERVIEW OF EBP

What is an Evidence-Based Practice¥EBP – employing clinical interventions that research has shown effective in helping consumers recover & achieve their goals. ¥EBP – services that have been empirically tested by independent researchers for their ability to reliably support consumers in reaching desired goals & outcomes. The degree to which a specific program or service adheres to the principles of the EBP model is termed fidelity. ¥Programs that adhere to closely to the EBP model are considered high Fidelity, where as programs that diverge significantly from the model are considered low Fidelity – poorer outcomes. ➢2-10 years to develop & establish EBP

Criteria for Evaluating Treatment Guidelines (APA, 2002)¥Evidence base for psychological intervention should be evaluated in terms of: 1.Efficacy -Establish causation between interventions and disorders under treatment. 2.Clinical Utility -Generalizability, feasibility (including patient acceptability), and costs and benefits of interventions

Evidence-Based Practice in Psychology¥EBPP – the research evidence that will assist the clinician in achieving the best outcome for the consumer. Includes: broad range of clinical activities: therapeutic relationship, assessment, case formulation. ¥Formulization of EBT Interventions: 1.Articulate the problem area; 2.Identify possible treatment areas 3.Pilot testing of intervention 4.Controlled evaluation of the intervention

EBPP vs. Empirically Supported Treatments (ESTs)EBPP¥More comprehensive concept. ¥Starts with PATIENT and asks what research evidence (including relevant results from RCTs) will assist the psychologist in achieving the best outcome. ¥encompasses a broader range of clinical activities (e.g., psychological assessment, case formulation, therapy relationships) ¥articulates a decision-making process for inte- grating multiple streams of research evidence ESTs¥Starts with TREATMENT and ask whether it works for a certain disorder or problem under specified circumstances. ¥specific psychological treatments that have been shown to be efficacious in controlled clinical trials

Principles of Evidence-based Mental health treatment1.People who are consumers are always at the center of decision making & evaluating outcomes. They have basic rights to information, discussion, respect, choices & autonomy. Right to information about their illness, effective treatment options, side effects, choices of treatment & expected outcomes. 2.Family members are often part of the consumers support network. They too, need respect, information, support & guidelines in order to be as effective as possible in supporting the recovery process. Nevertheless, the individual consumer maintains rights to autonomy & privacy.

Principles of Evidence-based Mental health treatment, cont.3.Clinicians have a moral & ethical obligation to understand & share scientific evidence regarding treatment. It is unacceptable to provide treatment that the Clinician finds most familiar with or personally prefers, rather than behavioral health treatment that corresponds to scientific evidence. 4.Evidence-Based treatments are not just about interventions, it includes: assessment, case formulation, therapeutic relationship.

Principles of Evidence-based Mental health treatment, cont.5.Agency & system administrators have an ethical obligation to make sure their clinicians are trained & supervised in evidence-based decision-making & practices. Ensure that actual services provided correspond to such guidelines, including feedback from consumers & their families. 6.Policy makers have an obligation to shift health systems toward evidence-based practices. This translates to structural supports: prioritization of resources, funding mechanisms, organizational structures, credentialing contracting, monitoring, quality assurance, training & development. (Mental Health Services Act)

Best Available Research Evidence¥Research will not always address all practice needs. (Generalizability/External Validity) ÐDesign ÐSampling representativeness (White, male, middle class) ¥Multiple research designs contribute to evidence-based practice, and different research designs are better suited to address different types of questions.

Multiple Types of Research Evidence● Clinical observation (including individual case studies) and basic psychological science are valu- able sources of innovations and hypotheses (the context of scientific discovery). ● Qualitative research can be used to describe the subjective, lived experiences of people, including participants in psychotherapy. ● Systematic case studies are particularly useful when aggregated—as in the form of practice research networks—for comparing individual patients with others with similar characteristics. ● Single-case experimental designs are particularly useful for establishing causal relationships in the context of an individual. ● Public health and ethnographic research are especially useful for tracking the availability, utilization, and acceptance of mental health treatments as well as suggesting ways of altering these treatments to maximize their utility in a given social context. ●

Multiple Types of Research Evidence (continued)● Process– outcome studies are especially valuable for identifying mechanisms of change. ● Studies of interventions as these are delivered in naturalistic settings (effectiveness research) are well suited for assessing the ecological validity of treatments. ● RCTs and their logical equivalents (efficacy re- search) are the standard for drawing causal infer- ences about the effects of interventions (context of scientific verification). ● Meta-analysis is a systematic means to synthesize results from multiple studies, test hypotheses, and quantitatively estimate the size of effects.

Clinical trials¥RCT – (Random Clinical trial) Emphasis on Efficacy. These studies are in highly controlled settings, with specially trained clinicians, carefully selected consumers & other constrained conditions for the sake of isolating & controlling treatment intervention. These favor cognitive & behavioral therapies. ➢Considered the “Gold Standard”

Clinical trials, cont.¥PCT (Practical Clinical Trials) Emphasis on Effectiveness. These studies select relevant interventions, plus diverse populations & settings. ➢Considered “Real World”

Best Practices¥Interventions deemed the most effective by a consensus of clinicians. Can be based on current beliefs, experts, prejudices of professional organizations or marketing in the industry. Often proven to be wrong/incorrect by scientific evidence.

Clinical expertise¥essential for identifying and integrating the best research evidence with clinical data ¥Psychologists are trained as scientists as well as practitioners. ¥Expertise develops from clinical and scientific training, theoretical understanding, experience, self-reflection, knowledge of research, and continuing professional education and training. ¥Experts are not infallible

Components of Clinical Expertise(a) assessment, diagnostic judgment, systematic case for- mulation, and treatment planning; (b) clinical decision making, treatment implementation, and monitoring of patient progress; (c) interpersonal expertise; (d) continual self-reflection and acquisition of skills; (e) appropriate evaluation and use of research evidence in both basic and applied psychological science; (f) understanding the influ- ence of individual and cultural differences on treatment; (g) seeking available resources (e.g., consultation, adjunctive or alternative services) as needed; (h) having a cogent rationale for clinical strategies.

Patient Characteristics, Culture, and Preferences ¥Normative data on “what works for whom” (Nathan & Gorman, 2002; Roth & Fonagy, 2004) provide essential guides to effective practice. ¥Psychological services are most likely to be effective when they are responsive to the patient’s specific problems, strengths, personality, sociocultural context, and preferences (Norcross, 2002)

Patient-related variables ! Outcomes(a) variations in presenting problems or disorders, etiology, concurrent symptoms or syndromes, and behavior; (b) chronological age, developmental status, developmental history, and life stage; (c) sociocultural and familial factors (e.g., gender, gender identity, ethnicity, race, social class, religion, disability status, family struc- ture, sexual orientation); (d) current environmental context, stressors (e.g., unemployment, recent life event), and social factors (e.g., institutional racism, health care disparities); (e) personal preferences, values, and preferences related to treatment (e.g., goals, beliefs, worldviews, treatment expectations).

Major issues in contemporary discourse on the delivery of mental health services1.How to make mental health services more culturally competent 2.How to implement evidence-based practices in real-world settings.

Common elements of empirically supported treatment ¥Treatment is short term; ¥the emphasis is present focused and problem focused; ¥skills training is stressed; ¥the therapeutic relationship is considered to be important; ¥homework is assigned ¥use of treatment manuals is also an essential aspect of empirically supported treatment

The need to expand the definition of evidence based practice… ¥Cultural adaptation is one method of mak- ing mental health services more culturally competent ¥cultural adaptations are consistent with the need to expand the definition of evidence-based practice to maximize external validity ¥An expanded definition of evidence-based practice supports the inclusion of discovery-oriented methodologies along with hypothesis testing in research on ethnic/racial minority populations

TASK¥Read: Evidence-Based Practice in Psychology by the APA Presidential Task Force on Evidence Based Practice

EMPIRICALLY SUPPORTED TREATMENTS

Cognitive Behavioral Therapy¥Popular among counselors, social workers, psychologists ¥More than 200 manuals, numerous publications ¥CBT’s emphasis on scientific analysis and quantifiable outcomes = most widely researched psychotherapy

CBT is about …¥Making changes in the client’s situation or environment toward the goal of alleviating or solving the presenting problem. ¥Teaching techniques likes cognitive restructuring to address cognitive errors, automatic dysfunctional thoughts …

Multi-cultural therapy (MCT)¥“fourth force” in the development of psychology (1. Psychoanalysis; 2. Behaviorism; 3. Humanism) ¥importance of cultural competence in the application of all forms of therapeutic practice and research

Convergence EBPP + CBT + MCT ¥By definition, EBPP require cultural competence, and cultural competence requires that psychologists consider the influence of culture throughout every aspect of their work. ¥CBT holds great promise for the development of culturally competent evidence-based practices.

CBT and MCT ¥both emphasize the need to tailor interventions to the unique needs and strengths of the individual ¥both emphasize empowerment ¥CBT focuses on conscious processes that can be easily articulated and assessed ¥CBT integrates assessment throughout therapy, an action that communicates respect for clients’ viewpoints regarding their progress; such demonstrations of respect are considered a core part of culturally responsive practice ¥CBT and MCT call attention to naturally occurring strengths and supports that can be used to facilitate change. ¥CBT’s behavioral roots emphasize the influence of environment on behavior, which fits well with MCT’s emphasis on cultural influences.

Culturally Responsive CBT1.Assess person’s and family’s needs with an emphasis on culturally respectful behavior. = 2.Identify culturally related strengths and supports. 3.Clarify what part of the problem is primarily environmental (i.e., external to the client) and what part is cognitive (internal), with attention to cultural influences. 4.For environmentally based problems, focus on helping the client to make changes that minimize stressors, increase personal strengths and supports, and build skills for interacting more effectively with the social and physical environment. 5.Validate clients’ self-reported experiences of oppression. 6.Emphasize collaboration over confrontation, with attention to client–therapist differences.

7.With cognitive restructuring, question the helpfulness (rather than the validity) of the thought or belief. 8.Do not challenge core cultural beliefs. 9.Use the client’s list of culturally related strengths and sup- ports to develop a list of helpful cognitions to replace the unhelpful ones. 10.Develop weekly homework assignments with an emphasis on cultural congruence and client direction

Efficacy vs. Effectiveness¥In the lab ¥Internal validity ¥Establish cause and effect between therapy and outcome ¥Real world ¥External validity

Note!¥Effective practice of evidence-based psychotherapy involves more than the mastery of specific procedures outlined in EST manuals. ¥Almost all ESTs rely on therapists’ having good nonspecific therapy skills Ðtreatment effects varied according to therapists’ competence ¥Client characteristics such as ability to form an alliance with the therapist (Krupnick et al 1996) and initial functioning (e.g. Elkin et al 1995) also proved to be important in predicting treatment outcome.

Division 12 Task Force on Psychological Interventions

EXAMPLES OF EMPIRICALLY VALIDATED TREATMENTS

Division 12 Task Force on Psychological Interventions

TASK¥Read: ¥Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52(1), 685–716. https://doi.org/10.1146/annurev.psych.52.1.685 ¥Frese, F. J., Stanley, J., Kress, K., & Vogel-Scibilia, S. (2001). Integrating evidence-based practices and the Recovery Model. Psychiatric Services, 52(11), 1462–1468. https://doi.org/10.1176/appi.ps.52.11.1462

Paradigm shift to Recovery Model¥Shift from psychodynamic insight orientated strategies to development of coping skills & strategies to manage illness & daily life tasks in order to have a meaningful life ¥Review of 10 components of the recovery model; stigma; strength model; economic sustainability of traditional programs

The recovery model ¥Recovery defined … Гa deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is a way of living a sat- isfying, hopeful, and contributing life, even with limitations caused by the illness. Recovery involves the devel- opment of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.” (William Anthony)

¥emphasizes that responsibility for and control of the recovery process must be given in large part to the person who has the condition. The recovery model

Conflict of modelsevidence-based approach ¥emphasizes external scientific realityrecovery model ¥stresses the importance of the phenomenological, subjective experiences and autonomous rights of persons who are in recovery. ¥Criticism: recovery model is subjective, not data based or scientific,

¥Treatment decisions cannot be made entirely on factual, scientific grounds. ¥Treatment decisions involve both medical facts and choices based on values.

Integrating the recovery model and evidence-based practices ¥For persons who are so seriously impaired in persons who are very disabled by mental illness are those most likely to benefit from objective, evidence-based approaches to treatment. ¥As such persons begin to benefit from treatments, they should be afforded opportunity for greater autonomy.

Evidence-Based Practice TreatmentModule 2 Maria Cristina Samaco-Zamora, Ph.D.

In this Module, we will be looking at:1.Evidence-Based Treatment Planning 2.Best practices 3.Cultural Competency 4.Legal/Ethical Issues

Clinical “Road Map”AssessmentDiagnosisTreatment PlanGoalsInterventions

DO: Review Documents¥In your e-learning site, open the documents: ¥Table of Content Handout ¥Clinical Documentation Handout ¥These are documents that you want to be familiar with.

READ¥In your e-learning site, open the documents: ¥From Science to Practice.

TREATMENT PLAN

What is a treatment plan?A written document that:ÐIdentifies the clientÕs most important goals for treatmentÐDescribes measurable, time sensitive steps toward achieving those goalsÐReflects a verbal agreement between the counselor and client

Who develops the Treatment Plan? ÐClient partners with treatment providers (ideally a multi-disciplinary team) to identify and agree on treatment goals and identify the strategies for achieving them

Treatment Planning¥Factors to consider: 1.Consumer’s Treatment Goals 2.Program constraints 3.Therapeutic modality 4.Funding for services 5.Consumer’s motivation (may or may not match goals)

There are many possible additions to a treatment plan. These are the basics.

Treatment Plan Process¥REVIEW: look at the assessments and other information regarding the client’s current status. Come up with some ideas on what the client should address and what to focus on in treatment. ¥DISCUSS: Therapist and client will discuss the plan for treatment. ¥Ask the client what outcomes they want. ¥Therapist may provide input on the clinical aspects of the treatment ¥WRITE the plan, which was developed collaboratively.

Parts of a Treatment Plan1.Problem Definition 2.Long-term goals 3.Objectives 4.Interventions 5.Diagnosis

1. Problem Definition¥Use psychosocial assessment to determine the most significant problem, include consumer input regarding symptoms and level of functioning. ¥Secondary problem/s are typically impairments are a result of the primary diagnosis. ¥Primary Problem: Depression ¥Secondary Problem: Anxiety (Clinical) or a psychosocial stressor (joblessness, recent break-up)

2. Long-Term Goals¥In collaboration with the consumer, use broad statements describing anticipated END RESULT of treatment. ¥A broad goal for resolving the target problem or challenge. This goal can be stated as a global, long-term goal that indicates positive growth. ¥

3. Create short-term objectives ¥Specific objectives for the consumer to achieve. ¥Stated in MEASURABLE or OBSERVABLE terms so accountability can be enhanced.¥Ex. 1.Increase participation in pleasurable activities from 1 time a week to 2 times per week per client report. 2.Client will identify and replace negative self-talk in session from 3 times per week to 2 times per week per client and therapist report. 3.Reduce conflict with family and/or co-workers from 4 times per week to 2 times per week per client report.

Formation of Goals¥Both therapist & consumer need to know what they’re working on ¥How progress can be measured; when the problem will be solved ¥Broken down into broad Long-term & Short-term Goals ➢Underlying Objectives – focus of work in individual sessions

Qualities of well-formed goals:1.Must be important to the consumer (more likely for the consumer to motivated to achieve when it’s their idea – Consumer Driven) 2.Must be small enough to be achievable (break down into actual steps) 3.Do not have to point to the ultimate achievement 4.Must be concrete, specific & behavioral (measurable) 5.Goals reflect the presence of something, not the absence of something (e.g. not being depressed anymore), instead – going for a walk, talking with friends 6.Must be realistic & achievable within the context of the consumer’s circumstances

DO: Read¥In your e-learning slide, read the document ¥Treatment Plan Goals and Objectives

4. Interventions¥This is what practitioner will do to help the client attain his/her objective ¥When developing Interventions, make sure the client understands … ¥What the practitioner will be doing ¥Description of the intervention ¥Why the practitioner is doing it ¥To address client’s mental health need ¥How often the practitioner will be doing it ¥When the practitioner will be done

Select therapeutic interventions¥At least one intervention should be paired with each objective to assist consumer in reaching the specific objective. ¥Determine if an EST exists, note the level of evidence, the match between the consumer and participants in the study and the clinician’s expertise in the EST. ¥Ex. 1.Engage client in behavioral activation by scheduling. 2.Using CBT client will identify negative automatic thoughts and replace them with reality-based cognitions. 3.Use modeling and/or role-playing to train client in assertive communication.

Read¥In your e-learning, open and read the document: ¥Explaining Rationale for CBT

Read¥The following resources are great resources for writing a treatment plan. ¥Clinician’s guide to writing Treatment Plan and Progress Notes ¥Mental Health Treatment Plans North Western Melbourne

WRITING REPORTS

Progress Notes¥Include the ff. Details: ¥Presenting Problem ¥Current clinical status ¥Specific intervention used consistent with client’s treatment plan ¥Reason for using intervention and client’s response to interventions(s) ¥Plan for subsequent service

Importance of Progress Notes¥It is a legal document. ¥Support the medical necessity for services. ¥Write it LEGIBLY! Auditors may disallow payment for a service if the notes cannot be read. Use BLACK INK for charting. ¥Documentation should be completed on the same day the service is provided. ¥Complete notes for each service contact. ¥Because charts are legal records, any essential changes must note WHO made the change.

Who can ask copies of Progress Notes¥Social Security – claiming disability ¥Other hospitals: emergency, transfers

Psychotherapy Notes, Process Notes, Private Notes¥notes taken by a mental health professional during a session with a patient ¥usually include the counselor’s or psychologist’s hypothesis regarding diagnosis, observations and any thoughts or feelings they have about a patient’s unique situation ¥Patient does NOT have the right to access these notes.

Process Notes might include:¥Observation ¥Hypothese ¥Questions to ask supervisor ¥Any thoughts or feelings relating to the therapy session

Process notes do NOT include¥Medication details or records ¥Test results ¥Summary of diagnosis or treatment plan ¥Summary of symptoms and prognosis ¥Summary of progress

BIRP Charting¥Behavioral Assessment – description of identified problems ➢Consumer’s presenting behavior ➢Mood, affect ➢Thought process ➢Physical presentation, if relevant ➢Potential for harming self or others, if relevant ➢Level of socialization, isolation, concentration or orientation (MSE) ➢Other behavioral issues

BIRP Charting, cont.¥Intervention* – describe intervention in terms of ➢Treatment Plan/objectives (at least 1 or 2 per session) ➢Provide specific approaches (i.e. CBT, psychoeducation) ➢Include modality – individual, group, family ➢Behavioral management issues ➢Consumer’s level of participation

BIRP Charting, cont.¥Response* – describe the consumer’s response to the interventions ➢Evaluate responses to interventions & treatment ➢Include reasons for continued level of care ➢Recommendation for change in treatment ¥Plan – on going; next session ➢Include specific issues to follow up on/crisis (i.e. CPS, psychiatrist) * Most important content areas

SOAP NOTES¥first introduced by Dr. Lawrence Weed about 50 years ago; their creation revolutionized the medical industry as the first proper method of documentation.

¥Subjective – Patient input. These are statements provided by the patient about their symptoms and current condition. ¥Objective – The objective section is about measurable results and quantitative data. All statements under objective should include a supporting piece of data. ¥Assessment – The assessment section is an analysis of the subjective and objective results. ¥Plan – The plan section is about treatment and rationale.

Treatment Plan Submission¥On your e-learning site, access the Assignment: Treatment Plan. ¥Submit the Assignment on or before July 1, 2023 at 11:59 PM

“ARE EMPIRICALLY SUPPORTED TREATMENTS VALID FOR MINORITIES?”

Definition: Culture¥dynamic process involving worldviews and ways of living in a physical and social environment shared by groups, which are passed from generation to generation and may be mod- ified by contacts between cultures in a particular social, historical, and political context.

Definition: Cultural Competence¥a set of problem-solving skills that includes a.the ability to recognize and understand the dynamic interplay between the heritage and adaptation dimensions of culture in shaping human behavior; b.the ability to use the knowledge acquired about an individual’s heritage and adaptational challenges to maximize the effectiveness of assessment, diagnosis, and treatment; c.internalization (i.e., incorporation into one’s clinical problem-solving repertoire) of this process of recognition, acquisition, and use of cultural dynamics so that it can be routinely applied to diverse groups.

A compelling case has been made on sociodemographic, clinical, ethical, and scientific grounds for cultural competence in the delivery of mental health services,

Cultural Adaptations of Evidence- Based Practices ¥any modification to an evidence-based treatment that involves changes in the ap- proach to service delivery, in the nature of the therapeutic relationship, or in components of the treatment itself to accommodate the cultural beliefs, attitudes, and behaviors of the target population.

Findings¥Standard empirically supported treatments are efficacious with persons of color suggest that modifications to service delivery may be sufficient cultural adaptations in many cases ¥Advocates of cultural competence and empirically supported treatment agree that treatments that have been shown to work with predominantly European American populations should be tried with ethnic/racial minority individuals ¥Ethnic/racial minorities in the United States do share some cultural characteristics with the main- stream of society, so it is reasonable to assume that standard treatments will work

Common elements of empirically supported treatment ¥Treatment is short term; ¥the emphasis is present focused and problem focused; ¥skills training is stressed; ¥the therapeutic relationship is considered to be important; ¥homework is assigned ¥use of treatment manuals is also an essential aspect of empirically supported treatment

The need to expand the definition of evidence based practice… ¥Cultural adaptation is one method of mak- ing mental health services more culturally competent ¥cultural adaptations are consistent with the need to expand the definition of evidence-based practice to maximize external validity ¥An expanded definition of evidence-based practice supports the inclusion of discovery-oriented methodologies along with hypothesis testing in research on ethnic/racial minority populations

Do: Read•ÒCultural Competence and Evidence-Based Practice in Mental Health ServicesÓ by Whaley, A. & Davis, K.E.

CULTURAL COMPETENCY

Fitzgerald (2000) discussed cultural competence stating, ¥It is about developing the ability to “see” a situation from multiple perspectives and, if necessary, to reconcile them. It is about developing multiple potential interpretations and using critical reflective thinking to choose which alternatives are most likely to provide effective strategies for care. It is about using such understandings to become more competent and effective professionals. (p. 184-185)

Approaching Differences Diagram

Attributes of Cultural Competence¥Attitudes/Beliefs and Cultural Awareness ¥Cultural Knowledge: understanding and sharing the world view of clients through cognitive empathy rather than affective empathy (Sue & Sue, 2013)

Developmental process for acquiring cultural knowledge (Belenky, Clinchy, Goldberger, & Tarule, 1986) 1.Silence 2.Received Knowing 3.Subjective Knowing 4.Procedural Knowing 5.Constructed Knowing

Personal Assessment Exercise (adapted from Ochs & Evans, 1993) Have you used/thought of any of the ff. statements?¥I don’t see you as (Black, White, Asian, Latino or Latina, Indian, gay, lesbian, disabled, and so forth), I see you as a person. ¥ I don’t know what’s the matter with [insert name of oppressed group]; after all, other people suffer oppression too. ¥Well, ____________________ are racists too. ¥I really don’t know what to say when I’m around ____________. ¥Some of my best friends are ___________________.

¥I’m afraid I might be mugged, robbed, or terrorized by one of them. ¥I really cannot do anything about racism [or discrimination, or oppression]. It is not my problem. I have enough to worry about. ¥I don’t have any prejudices against ______________; I’ve never even met any of them. ¥I just feel overwhelmed with how much I have to learn about other cultures.

¥I don’t see why we have to put everything we write into two languages. Non-English speakers are going to have to learn to speak English anyway if they want to succeed in this country. ¥I’d really prefer to buy a house in a less integrated area. Not that I object to living in a neighborhood with people of color, I’m just afraid the property values may decrease in the future

Attributes of Cultural Competence (continued)¥Cultural Skills: ability to apply acquired cultural knowledge in providing culturally appropriate interventions to culturally diverse clients

Do: Read •ÒIntegrating Evidence-Based Practice, CognitiveÐBehavior Therapy, and Multicultural Therapy: Ten Steps for Culturally Competent PracticeÓ By Hays. P.

Legal aspects: Basics

Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) ¥address the use and disclosure of individuals’ health information by organizations subject to the Privacy Rule as well as standards for individuals’ privacy rights to understand and control how their health information is used

Permitted Disclosures¥Patient has consented in writing ¥Purpose of the disclosure ¥How much and what kind of information is to be disclosed ¥A minor must always sign the consent form for a program to release information even to his or her parent or guardian

¥Crimes on program premises or against program personnel Ðlimited information to law enforcement officers Ðdirectly related to crimes and threats to commit crimes on program premises or against program personnel and must be limited to the circumstances of the incident and the patient’s status, name, address and last known whereabouts ¥Child abuse reporting ¥Medical emergencies

Do: Read•ÒLegal and Ethical Aspects of Mental Health CareÓ

 

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