Expert answer:wk 4 Q1, q2

Expert answer:2 PP per question, in text citing Q1 – Study
the “Case Formulation and the Diagnostic Process” media piece. Now,
summarize the process of assessment, diagnosing, and treatment in your
own words. What are some implications for not including the client in
the creation of an effective treatment plan? How does the therapist
support the client for beneficial behaviors to progress towards
treatment goals?Q2 – How are treatment goals/objectives
influenced by a therapist’s theory of choice? Cite two examples of how
the counseling theory being utilized in therapy could dramatically alter
treatment goals. Give an example or describe a reason that would prompt
you to make a referral.
case_formulation_and_the_diagnostic_process.docx

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Case Formulation and the Diagnostic Process
The Case Formulation and the Diagnostic Process media piece illustrates the typical progression
from screening to active implementation of the treatment plan in clinical mental health
counseling. Within this process, you will see the Process of Diagnosing. Pay close attention to
this process, as it is important to consider provisional diagnoses, determine final diagnosis, use
subtypes and specifiers, decide upon principal diagnosis (when more than one diagnosis), and
document appropriately (including ICD-10-CM Codes).
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Treatment begins from the moment the client makes contact, including the very first call
for a screening. Remember to avoid imposing values or denying services based on
cultural/value differences throughout this process.
Screening – Initial (short) screening to assess if client is appropriate for services.
Sometimes is done over the phone.
Informed Consent – Informed Consent in the Counseling Relationship in ACA Code of Ethics
(American Counseling Association, 2014).
Biopsychosocial – Gathering information: presenting problems; social history; family dynamics;
mental health history; academic/intellectual history; medical history; current meds; legal
history; victim status; spiritual orientation; vocational history; previous treatment episodes;
mini-mental (appearance, affect, orientation, speech, judgment, etc.); suicidal/homicidal
ideation and psychosis; strengths and supports; and clinical summary, diagnosis, and treatment
recommendations.
Clinical Assessments – Becks Depression? SASSI? ASAM Criteria to assess level of care?
Begin the Process of Diagnosing – Consider rule outs, provisional, and determined diagnoses
made using the DSM-5 (American Psychiatric Association, 2013).
Provisional Diagnosis – Begin formulating ideas of provisional diagnosis. These are diagnoses for
which you believe the client may meet full criteria; however, you need to gather more
information to confirm that they meet criteria.
Diagnosing: Determine Diagnosis – “On the basis of the clinical interview, text descriptions,
criteria, and clinician judgment, a final diagnosis is made” (American Psychiatric Association,
2013, p. 21). Multiple diagnoses may be made.
Diagnosing: Use Subtypes and Specifiers – Consider “provisional” as a specifier for diagnoses
that still need to be ruled out.
Diagnosing: Make Principal Diagnosis – If more than one diagnosis, which one is chiefly
responsible for client treatment?
Documentation of Diagnosis – Document DSM-5 diagnosis including ICD-10-CM Code. Use codes
and wording in this fashion: 305.90 (F10.20) Alcohol Use Disorder, moderate.
Master Problem List – Prioritize problems: Client may have many problems/issues – but client
and counselor must decide which to address first. Specifically define the problems. What are the
most critical presenting issues?
Develop Goals – These are broad, long-term goals.
Objectives – Objectives must be measurable! These will state what the client will do and what
the clinician will do. Use strategies from evidence-based therapies. Under each long-term, broad
goal may be two or several specific objectives stating (measurably) what will occur (Jogsma,
2006, p. 2). Not: Client will begin to like his job. Instead: Client will report significantly increased
Case Formulation and the Diagnostic Process
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levels of satisfaction and acceptance of other people at work (on a scale of 1-10). Not: Client will
begin to realize her self-worth. Instead: Client will make a list of 20 positive things about herself.
Treatment – Implement interventions/strategies based on treatment plan (which is made up of
problems, goals, and objectives).
Informal Assessments – Informal assessments and monitor/ goals met? Evaluate periodically
(each week for inpatient, monthly for intensive outpatient, etc.).
Treatment Plan Revisions – Revise and make additions to the treatment plan: The treatment
plan is a living document. That is, it is to be updated and changed as treatment needs change
and/or objectives and goals are reached.
References
American Counseling Association. (2014). ACA code of ethics. Retrieved from
http://www.counseling.org/Resources/aca-code-of-ethics.pdf
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: American Psychiatric Publishing.
Jongsma, A. (Ed.). (2006). The child psychotherapy treatment planner (4th ed.). Hoboken, NJ:
Wiley.
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