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Chapter 8 Summary

Chapter 8 Summary

Chapter Review

Assessment entails collecting client information to understand their treatment needs, current functioning, and risk level. According to Prout et al. (2022), therapists often conduct assessment throughout therapy to identify treatment goals and assess progress. The process may entail interviewing the client, observing their behavior (e.g., behavioral assessment), testing, and reviewing important records.

Behavioral assessment entails observing the client in a naturalistic setting to acquire information regarding their behavior. One primary type of behavioral assessment is functional behavior assessment (FBA). This method entails observing a client to ascertain the various factors that led to a specific behavior, as well as the motivating factors. The FBA aims to create a supposition about why a given behavior occurs and why it persists over time by examining what triggers and motivates the behavior. Understanding these factors leads to an in-depth understanding of the client’s problems and points towards a suitable treatment plan.

Counselors and psychologists often use collateral data to understand client’s problems. The data can be obtained from different sources, including past psychiatric, educational, and medical records. Counselors and psychologists also conduct tests to measure clients' symptoms, determine diagnoses, and select the most suitable treatment plans. Once they have created a treatment plan, they must discuss it with the client. The client must fully understand and consent to the plan.

Assessment

Prout et al. (2022) define assessment as the process of collecting data about clients to understand their treatment needs, current functioning, and risk level. Simply put, assessment is a way of understanding clients’ strengths and weaknesses, such as coping skills, risk of self-harm, and current distress. It may comprise all methods a therapist may utilize to collect information about individuals, couples, or families seeking therapy. More specifically, assessment may entail interviewing clients, observing clients’ behaviors, testing, and reviewing client’s records. This process is not just conducted at the start of therapy. It might be conducted continually during therapy to monitor progress.

Box 8.2

Box 8.2 is a sample consent form for disclosure of client information or records. The consent form clearly indicates the name of the counselor, along with her address. It also stipulates records or information to be disclosed or released. These include therapy notes, a summary of treatment, billing records, termination/transfer summary, tests taken and scores, etc. The client must sign the consent form at the end, agreeing that they acknowledge and understand that they are waiving their rights to confidentiality.

Diagnosis

Therapists conduct assessments to gain a better understanding of the client. This entails identifying signs and symptoms. Diagnosis entails classifying client’s symptoms. It describes the nature of the problem the client is experiencing and offers a way for practitioners to communicate effectively with one another and insurance companies. According to Prout and colleagues (2022), diagnosis helps clinicians and clients quickly understand major mental health issues. For instance, instead of indicating that the client presents symptoms such as irritability, insomnia, sadness, poor concentration, lack of energy, and reduced appetite, a clinician may describe the client as depressed. Nevertheless, a diagnosis alone cannot explain a person’s unique state of mental health.

DSM-5

DSM-5 stands for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. This is the reference utilized by clinicians to make mental health diagnoses. Thus, for a client to be diagnosed with a mental illness, they must meet specific criteria.

Treatment Plans

A case formulation must contain every detail necessary to create a treatment plan that helps address the client’s problem. A mental health professional must integrate all information collected during assessment to craft a cohesive description of the client’s behaviors, feelings, and thoughts. A mental health professional should also illuminate the factors that could have caused the problem (e.g., human history, experience, biological mechanisms, etc.) and the factors that could be keeping the client in the problem (i.e., poor coping skills, dysfunctional relationships, maladaptive behaviors, etc.) to identify a suitable treatment plan.

A better case formulation results in a more robust treatment plan. According to reports, practitioners utilize different strategies to create their treatment plans. One research study asked therapists to conduct a case study and think about what treatment they should provide to the client. The research discovered that mental health professionals interpreted the client’s problem, recommended a suitable intervention, and examined supporting evidence but did consider any alternative treatments.

A treatment plan encompasses goals for the client to attain and specific objectives and interventions. According to Prout and colleagues (2022), creating a treatment plan must be a collaborative effort between a clinician and the client. The two parties should agree on the goals for treatment and create a clear path to attaining those goals.

References

Prout, T. A., Wadkins, M. J., & Tatianna Kufferath-Lin, P. (2022).  Essential interviewing and counseling skills: An integrated approach to practice (2nd ed.). Springer Publishing Company.