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Chapter 1 Clinical Assessment and Treatment Planning

Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T

LEARNING OBJECTIVES FOR

CLINICAL ASSESSMENT and TREATMENT PLANNING

After reading this section you will learn the answers to the following questions:

  1. What are the components of an effective Clinical Assessment and Treatment plan?
  2. What is the “Why Now” question?
  3. What needs to be included in a thorough Psychosocial History?
  4. Why is it important to have a thorough family history on a client that goes back at least three generations?
  5. What are the ACE factors and why should clinicians include them in an assessment?
  6. What are the components of a Mental Status Exam and why should a clinician include them in an assessment?
  7. What are the three components of a diagnosis: principal, provisional and other conditions that may be a focus of clinical attention, and why are they important?
  8. What are the components of a good Treatment Plan and what guidebooks can you use in developing clinical treatment plans for your clients?
  9. Why would you always want three major goals with three objectives for each, with one intervention for each objective under each goal?
  10. What is the purpose of doing a thorough Clinical Assessment and Treatment Plan?
  11. What should be included in quality progress notes?
  12. What should be included in quality case staffing reports?

Before a Mental Health Professional can determine the clinical course or direction of interventions with individual clients, there first must be a complete clinical assessment to determine the clients’ needs. To do this a Mental Health Professional needs to find out initially from the client why he/she is coming in now? Then the clinician needs to conduct a thorough psychosocial history. Only after the clinician has gathered the relevant information is he/she able to develop a treatment plan.

 

Initial Assessment Components

John walked into your office ready for his first appointment. You help him relax and find out if he has filled out all of the forms you had mailed him including your Informed Consent Form and the Biographical Information Form. Once he settles in you ask, “What brought you in today? Help me understand what is going on with you so that I can better help you.”

 

You will begin the assessment by asking the client “Why now?” This is a description of presenting problems with a list of specific symptoms/complaints that justify diagnosis and need for treatment and duration of symptoms (estimate if unknown). 

“John, thanks for sharing what has been happening. Before we begin to address those anxiety issues I would like a little more information on you.”

 

Then next item is a Clinical Mental Health History which includes prior treatment for psychiatric and substance abuse problems, including hospitalizations. Next, you will want to find out if the client currently is taking psychotropic medications, and if so, who is prescribing these and the dosage amounts.

“So John, this is your first time seeing a counselor. Have you ever had a doctor prescribe you medication to address your anxiety?”

 

You will then want to probe into the client’s medical history. This should include the status of the client’s present health and relevant current or former medical conditions which could relate to the presenting problems.

“John, what has your health been like in the past few years? Have you had any medical emergencies which needed treatment? Do you have any chronic health problems which feed your anxiety? When is the last time you had a complete physical?”

 

Next, you will want to delve into the family history which includes a family geneogram, a pictorial display of a person’s family relationships and medical history.  This also should include mental health and/or substance abuse disorders and/or treatment.

“So John, has anyone in your family had any major medical or emotional issues? Was there any relative who had experienced in the past the level of anxiety you are reporting?”

 

Next you will next want to learn about your client’s social history which includes his/her educational background and community involvement. You will then ask about your client’s vocational life.   This considers the individual’s work history and level of current employment. This information often is crucial in uncovering the “Why now?”

“John, tell me a little about your educational background. What was the highest grade you completed? How were your grades? How difficult was it to be in school for you? Did you have a good number of friends during your time in school? How about now, do you have close friends you get together with or talk to? I see you are employed full time. What type of work do you do and is your job satisfying for you?”

 

The next part of the assessment looks at both the client’s strengths and liabilities which you will want to pull into the clinical situation.

“John, you seem to have a good understanding of what triggers your anxiety. What have you been doing to lessen those triggers from getting to you? How long have you been dealing with this anxiety and have you ever talked to a family member or friend about it? How open are you to making changes in your life to lessen the intensity of the anxiety which has been getting you down?”

 

The assessment includes a review of the relevant ACE (Adverse Childhood Experience) Factors which include: 1. Emotional Abuse; 2. Physical Abuse; 3. Sexual Abuse; Neglect 4. Emotional Neglect; 5. Physical Neglect and Household Dysfunction; 6. Mother was treated violently; 7. Household substance abuse; 8. Household mental illness; 9. Parental separation or divorce and 10. Incarcerated household member (CDC, 2013).

“John, in your past would you say you were ever abused, be it physical, sexual, or emotional? Were you ever physically or emotionally neglected? Finally, was anyone in your family troubled by mental health or substance abuse issues? Did you live with both your parents all your childhood? Were your parent cooperative with one another or were they typically arguing and upset with one another? Were your parents divorced? Was either of your parents at anytime incarcerated?”

 

The Assessment then concludes with a Mental Status Examination (Polanski and Hinkle, 2000) which includes assessing the following client descriptions at the moment of intake: Appearance; Consciousness; Orientation; Speech; Affect; Mood; Concentration; Activity Level; Thoughts; Memory; and Judgment. 

The next section of the Initial Assessment is the diagnosis based on DSM-5 Criteria which lists: the Principal diagnosis, any Provisional diagnosis and then Other Conditions That May Be a Focus of Clinical Attention.

 

The last portion of the initial clinical assessment is the Treatment Plan with 3 Long Term Goals and 3 Behavioral Objectives per Goal and 3 Clinical Interventions per Goal e.g. one per each objective. 

Initial Mental Health Assessment (Messina, 2016)

Name of Client:                                                        

Date of Assessment:

Date of Birth of Client:                                            

Chronological Age of Client:

Educational Level:                                                   

Marital Status:

Ethnic Origin or Race:                                            

Referred by:

Why now? Description of presenting problems with list if specific symptoms/complaints that justify diagnosis and need for treatment and duration of symptoms (estimate if unknown).

Clinical Mental Health History: Include prior treatment for psychiatric and substance abuse problems, including hospitalizations.

Current psychotropic medications: Listing of all medications including who prescribes them and size of each prescription.

Medical History: Status of client’s current health and relevant current or former medical conditions which could relate to the presenting problems.

Family History: Describe the Family of Origin (Including a Family Genogram) and then describe relevant Family Racial/Cultural; Family Mental Health and/or Substance Abuse History.

Social History: First describe school history and then describe community involvement. Finally report on the Racial/Cultural Development of the client and indicate if there is a need to provide modifications due to Racial/Cultural needs including: language; client attributes; metaphors; content; concepts; goals; methods; and context.

Vocational History: Describe current level of employment and then relevant past employment history.

Client’s strengths: __Motivated for therapy __Insightful into symptoms __Adequate judgment __Intelligent __Verbally engaging __Memory intact

Client’s liabilities: __Weak social support system __Impaired perception: vision, hearing, other__ Risk of decompensating if not treated

Relevant ACE (Adverse Childhood Experiences)

Abuse

__ 1. Emotional Abuse

__ 2. Physical Abuse

__ 3. Sexual Abuse

Neglect

__ 4. Emotional Neglect

__ 5. Physical Neglect

Household Dysfunction

__ 6. Mother was treated violently

__ 7. Household substance abuse

__ 8. Household mental illness

__ 9. Parental separation or divorce

__ 10. Incarcerated household member

Mental Status Exam

Appearance:

__appropriate __well groomed __bizarre __disheveled

__other (describe)

Consciousness:

 __alert __drowsy __vegetative

__other (describe)

Orientation:

 __to person __to place __to time

Speech:

 __appropriate __spontaneous __rapid __pressured __slow __slurred

__other (describe)

Affect:

 __sad __tearful __flat __anxious __angry __concerned __agitated __elated __calm __inappropriate __broad __restricted __labile __blunted

__other (describe)

Mood:

 __euthymic __dysphoric __elevated __euphoric __expansive __irritable __depressed

__other (describe)

Concentration:

  __good __fair __poor __distracted

Activity Level:

__appropriate __agitated __psychomotor retardation __tremulous __restless

__other (describe)

Thoughts:

__appropriate __logical __coherent __blocked __loose association __hallucinations __delusions __circumstantial __tangential

__other (describe)

Memory:

__intact __short term deficits __long term deficits

Judgment:

__good __fair __poor

Tentative Diagnosis

Principal Diagnosis (List as many that are applicable)

Provisional Diagnosis (if any)

Other Conditions That May Be a Focus of Clinical Attention (list all relevant conditions)

(Using the ICD-10-CM Codes and DSM-5 Classifications you need to post the above using the Codes and Formal Name with all relevant specifiers)

Treatment Plan

(First: List three long term goals. Second: Under each goal then list at least three objectives for each goal which are distinct and related just to the goal listed. Third: Under each objective listed then list a specific Therapeutic Intervention which is related to each the three objectives per goal and describe what theoretical model each intervention comes from (eg: CBT, Behavioral, etc.).This will result in a total of 3 Long Term Goals, 9 Objectives and 9 Interventions).

Long Term Treatment Goal #1

1.         Short Term Treatment Objective #1

  • Therapeutic Intervention #1

2.         Short Term Treatment Objective #2

  • Therapeutic Intervention #1

3.         Short Term  Treatment Objective #3

  • Therapeutic Intervention #3

Long Term Treatment Goal #2

1.         Short Term Treatment Objective #1

  • Therapeutic Intervention #1

2.         Short Term Treatment Objective #2

  • Therapeutic Intervention #1

3.         Short Term  Treatment Objective #3

  • Therapeutic Intervention #3

Long Term Treatment Goal #3

1.         Short Term Treatment Objective #1

  • Therapeutic Intervention #1

2.         Short Term Treatment Objective #2

  • Therapeutic Intervention #1

3.         Short Term  Treatment Objective #3

  • Therapeutic Intervention #3

(In developing your treatment plan you can utilize Treatment Planning tools such as 

Jongsma, Jr., A.E., Peterson, L.M. & Bruce, T.J. (2014) The complete adult psychotherapy treatment planner (Fifth edition). New York, NY:  John Wiley & Sons, Inc.)

Clinical Progress Notes

As a Mental Health Professional, you will best serve your clients by keeping track of their progress after every scheduled clinical session. The following outline will assist you as you create the framework for your client’s progress notes. 

  1. Address treatment goal and objective in this session:
  2. List client’s homework results from last session:
  3. Note clinical intervention used in current session:
  4. Note client’s response to intervention used:
  5. List resistance to change/barriers to goal attainment:
  6. Note progress towards goals and objectives witnessed in session:
  7. Note client’s homework at end of session:
  8. Plan for next session’s interventions:

Implementing the above outline when you see a client will provide you with a consistent framework and point of reference and will provide you with a history so you can always refer to the original clinical assessment and treatment plans, goals, objectives and intended interventions. Keeping accurate progress notes also creates transparency. Not only are you accountable to your clients, but also to their agencies and/or third party payors involved in providing mental health services to their clients (Messina, 2013). 

Clinical Progress Notes

Client’s Name:

Date:                                                                                                                                                  

Client’s Principal Diagnosis:

Address treatment goal and objective in this session:

List results of client’s homework from last session:

Note clinical intervention used in session:
Note client’s response to intervention used:

List resistance to change/barriers to goal attainment:

Note progress towards goals and objectives witnessed in session:

Note homework given client at end of session:

Plan for next session’s interventions:

Submitted by:                                                                        Date:

Case Study Report Format

While in training for practicum and internships, Mental Health Professionals will need to provide a complete Case Study Report concerning clients whom they have seen. These case studies should include not only the above Initial Assessment Report format but also the following:

Course of Treatment: 

Give a narrative description of the course of treatment with the client and be sure to describe:

  1. How did the client respond to the interventions?
  2. What resistance was present during the client’s course of treatment?
  3. How open and free was the client to participating in the treatment plan?
  4. What changes if any did you need to make in this client’s treatment plan?
  5. Was there a change in your tentative diagnosis at the end of treatment with this client?
  6. What would you have done differently with this client knowing what you know today?
  7. What did you learn about yourself as a counselor from working with this client?

Impact of Treatment Plan:

  1. Results for Long Term Goal #1
  2. Results for Long Term Goal #2
  3. Results for Long Term Goal #3

Guidebooks for EBP-Treatment Planning

Dattillo, F.M. & Jongsma, A. (2014). The family therapy treatment planner with DSM-5 updates (Second edition). Hoboken, N J: John Wiley & Sons Inc. 

 

Jongsma, Jr., A.E., Peterson, L.M. & Bruce, T.J. (2014) The complete adult psychotherapy treatment planner (Fifth edition). New York, NY:  John Wiley & Sons, Inc. 


Jongsma, A.E., Peterson, L.M. McInnis, W.P. & Bruce, T. (2014). The adolescent psychotherapy treatment planner (Fifth edition).  Hoboken, NJ: Wiley & Sons.

 

Jongsma, A.E., Peterson, L.M. McInnis, W.P. & Bruce, T. (2014). The child psychotherapy treatment planner (Fifth edition).  Hoboken, NJ: Wiley & Sons. 

 

Kolski, T.D., Jongsma, A.E., Myer, R.A. (2014) The crisis counseling and traumatic events treatment planner (Second edition). Hoboken, NJ: Wiley & Sons. 

 

Perkinson, R., Jongsma, A. and Bruce, T. (2014). The addiction treatment planner (Fifth edition). Hoboken, NJ: John Wiley & Sons. 

References on Report Writing for Clinical Assessment, Treatment


Centers for Disease Control and Prevention (CDC) (2013). Adverse childhood

experiences (ACE) study. Retrieved at: http://www.cdc.gov/ace/index.htm

 

Jongsma, Jr., A.E. and Peterson, L.M. (2009) The complete adult psychotherapy

treatment planner. New York, NY:  John Wiley & Sons, Inc.

 

Messina, J.J. (2015). Clinical assessment and treatment planning

Retrieved at: http://coping.us/cliniciantreatmenttools/clinicalassessmentplan.html

 

Polanski, P.J. and Hinkle, S. (2000). The mental status examination: Its use by

professional counselors. Journal of Counseling and Development, 78 (Summer), 357-364.

Mental Health Awareness Through Wristbands

An excellent resource to spread the word on Mental Health Awareness is avaiable at: https://www.wristbandexpress.com/content/mental-health-awareness-through-wristbands

This wonderful resource was pointed out to us by: a Girl Scout Troop in Seattle Wasington and we thank them for their conscientious effort to get word out about Mental Health Awareness.

WHERE DO I GO FROM HERE?

CONCERNING CLINICAL ASSESSMENT and TREATMENT PLANNING

Now that you have read this section, in your “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practice Clinical Assessment, Diagnosis and Treatment Planning in my clinical work?
  3. Why is it important that I learn more about this topic?
  4. What more do I need to know about this topic?
  5. Where can I go to obtain more information about this topic?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on this topic?