{"id":1286,"date":"2020-08-25T21:24:30","date_gmt":"2020-08-25T21:24:30","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/abnormalpsych\/?post_type=chapter&#038;p=1286"},"modified":"2022-07-26T20:06:53","modified_gmt":"2022-07-26T20:06:53","slug":"the-diagnostic-process","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/chapter\/the-diagnostic-process\/","title":{"raw":"The Diagnostic Process","rendered":"The Diagnostic Process"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul id=\"id_0077421000_001_001824\" class=\"objectives\">\r\n \t<li id=\"id_0077421000_001_001829\" class=\"objective\" value=\"4\">Explain the steps and people involved in the diagnostic process, including the case formulation<\/li>\r\n<\/ul>\r\n<\/div>\r\nThe word <strong>diagnosis<\/strong> commonly refers to t<span style=\"font-size: 1em;\">he identification of the nature and cause of an illness<\/span><span style=\"font-size: 1em;\">. When a mental health professional diagnoses a client or patient, the first steps can be summarized as gathering information, narrowing down the options, and formulating a diagnostic impression.\u00a0<\/span>\r\n\r\nThe diagnostic process involves gathering relevant information\u00a0from a person\u00a0through a detailed interview that includes finding out the person\u2019s main concerns, their symptoms, and their life history.\u00a0This information includes the results from psychological\u00a0<span style=\"font-size: 1em;\">tests or questionnaires and may include i<\/span><span style=\"font-size: 1rem; text-align: initial;\">nformation obtained from the person\u2019s family and\/or from previous treatment records. Mental health professionals\u00a0<\/span>use this first phase of working with clients before proceeding with the treatment itself. More specifically, before\u00a0<span style=\"font-size: 1em;\">a<\/span><span style=\"font-size: 1em; text-align: initial;\">\u00a0diagnosis is given,\u00a0<\/span>they\u00a0<span style=\"font-size: 1em;\">determine whether the person\u2019s symptoms match the <em>DSM<\/em>\u2019s criteria for a particular mental disorder, and if there is\u00a0<\/span><span style=\"font-size: 1em;\">a significant level of disturbance in the person\u2019s cognitive, emotional, or behavioral functioning.\u00a0<\/span><span style=\"font-size: 1em; text-align: initial;\">\u00a0<\/span>\r\n<h2><span id=\"Clients,_survivors,_and_consumers\" class=\"mw-headline\">Clients, Consumers, and Patients<\/span><\/h2>\r\n<span style=\"font-size: 1em; text-align: initial;\">Why all the different terms? <strong>Patient<\/strong> and <strong>client<\/strong> are terms that carry different connotations, often depending on the method of treatment, or treatment site. For many professionals, a <em>patient<\/em>\u00a0is any recipient of\u00a0health care\u00a0services performed by\u00a0healthcare professionals, and <em>c<\/em><\/span><em>lient<\/em>\u00a0reflects that people in treatment collaborate with those who treat them, notably, the <strong>clinician<\/strong>\u2014a\u00a0professional who works directly with patients or clients and may diagnose, treat, and otherwise care for them.\u00a0A term adopted by many users of psychiatric services is <em>consumer<\/em>.\" This term was chosen to eliminate the \"patient\" label and restore the person to an active role as a user or consumer of services.[footnote]Halpern, L, Trachtman, H. and Duckworth, K. \"From Within: A Consumer Perspective on Psychiatric Hospitals,\" in Textbook of Hospital Psychiatry, S. Sharfstein, F. Dickerson and J. Oldham eds. American Psychiatric Publishing, 2009, pp. 237\u2013244.[\/footnote] The terms\u00a0<i>clients<\/i>\u00a0and\u00a0<i>consumers<\/i>\u00a0imply a much more active role on the part of the individual and therefore imply that\u00a0<span style=\"font-size: 1em;\">h<\/span><span style=\"font-size: 1em;\">ealthcare\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">professionals are not the only ones who have expertise in healthy functioning.<\/span>\r\n<h2><span style=\"background-color: #ffffff;\">Diagnostic Procedures<\/span><\/h2>\r\nThe main goal of the information-gathering model is to accurately diagnose, plan treatments, and evaluate treatment effectiveness. The key to diagnosis is gaining as clear a description as possible of a client's or patient's symptoms. Mental health professionals listen to what the client or patient reports, and they observe quite a number of things, such as\u00a0<span style=\"font-size: 1em;\">behavior and emotional expression<\/span><span style=\"font-size: 1rem; text-align: initial;\">.\u00a0Routine diagnostic practice in mental health services typically involves an interview known as a\u00a0<strong>mental status examination<\/strong>, where evaluations are made of appearance and behavior, self-reported symptoms, mental health history, and current life circumstances.<\/span>\r\n\r\nWe will discuss a variety of assessment tools used by mental health professionals to determine the extent to which these symptoms correspond with the diagnostic criteria of a given disorder. This approach to diagnosis\u00a0is more systematic, and\u00a0allows one to determine\u00a0the exact nature of a client's symptoms, the length of time the client has experienced these symptoms, and any associated symptoms.\r\n<h3><strong>Elements of a Diagnosis<\/strong><\/h3>\r\nBy\u00a0<span style=\"font-size: 1em;\">listening to clients as they describe the experience of their symptoms, and following up with <\/span>assessment<span style=\"font-size: 1em;\">\u00a0tools (not always, but often), the mental health professional<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0begins to formulate the\u00a0<\/span><strong style=\"font-size: 1rem; text-align: initial;\">principal diagnosis<\/strong><span style=\"font-size: 1rem; text-align: initial;\">\u2014or the reason for the visit. This means determining the single diagnosis that is most relevant to the person's\u00a0chief complaint\u00a0or need for treatment; this diagnosis will be the main\u00a0focus of clinical attention or treatment.<\/span>\r\n\r\n<span style=\"font-size: 1rem; text-align: initial;\"> After determining the primary reason the individual is seeking professional help, a<\/span>\u00a0<strong>differential diagnosis<\/strong>\u00a0is commonly used. Two different diagnoses can be attached to a patient who is exhibiting symptoms that could fit into either diagnosis. For example, a patient who has been diagnosed with bipolar disorder may also be given a differential diagnosis of borderline personality disorder, given the similarity in the symptoms of both conditions. Where multiple alternatives are possible, this method is akin to the\u00a0process of elimination or ruling out of alternative diagnoses, a crucial step in the diagnostic process.\r\n\r\n<span style=\"font-size: 1rem; text-align: initial;\">Many patients have additional diagnoses. <strong>C<\/strong><\/span><strong>omorbidity<\/strong>\u00a0refers to the presence of more than one diagnosis occurring in an individual at the same time.\u00a0In the context of mental health, comorbidity often refers to\u00a0disorders\u00a0that are often coexistent with each other, such as\u00a0substance<span style=\"font-size: 1em;\">\u00a0use disorder and\u00a0<\/span><span style=\"text-align: initial;\"><span style=\"font-size: 1rem;\">depression (the most common comorbidities involve the concurrence of\u00a0<\/span><span style=\"font-size: 1em;\">substance<span style=\"font-size: 1em;\">\u00a0use disorders\u00a0<\/span><\/span><span style=\"font-size: 1rem;\">with other mental disorders). Multiple diagnoses are usually presented in a hierarchy\u00a0descending from the condition of most significance to that of the least concern.<\/span><\/span>\r\n<h2>The Case Formulation<\/h2>\r\n<div id=\"post-230\" class=\"standard post-230 chapter type-chapter status-publish hentry\">\r\n<div class=\"entry-content\">\r\n\r\nOnce the mental health professional makes a formal diagnosis, they then analyze the factors that may have influenced the patient or client\u2019s current psychological state. A\u00a0<b>clinical formulation<\/b>, also known as\u00a0case formulation or case conceptualization,\u00a0is that analysis, or a theoretically based explanation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems (e.g., background history, presenting concerns, and manifestation and progression of behavioral signs and symptoms over time), and is considered an adjunct or alternative approach to the more categorical approach of psychiatric\u00a0diagnosis.\u00a0These formulations are used to communicate a\u00a0hypothesis\u00a0and provide a framework for developing the most suitable treatment approach, rather than labels or diagnostic codes. It gives a rich description of the client\u2019s personal history and pieces together how the disorder evolved. It is most commonly used by\u00a0clinical psychologists\u00a0and\u00a0psychiatrists\u00a0and is deemed to be a core component of these professions.\u00a0Mental health nurses and social workers may also use formulations. As mental health professionals, we need to consider both the\u00a0purpose of our communication and the audience for that communication. As\u00a0professionals, we must also consider the potential misuse of documents by others,\u00a0which will influence the way that we present our case formulation.\r\n<h2><span id=\"Types_of_formulation\" class=\"mw-headline\">Types of Formulation<\/span><\/h2>\r\nDifferent psychological schools or models utilize clinical formulations, including cognitive-behavioral therapy\u00a0(CBT) and related therapies:\u00a0systemic therapy,\u00a0psychodynamic therapy,\u00a0and\u00a0applied behavior analysis.\u00a0The structure and content of a clinical formulation is determined by the psychological model (which we will examine more closely in another module). Most systems of formulation contain the following broad categories of information:\r\n<ul>\r\n \t<li>symptoms and problems<\/li>\r\n \t<li>precipitating stressors or events<\/li>\r\n \t<li>predisposing life events or stressors<\/li>\r\n \t<li>an explanatory mechanism that links the preceding categories together<\/li>\r\n \t<li>a description of the precipitants and maintaining influences of the person\u2019s problems<\/li>\r\n<\/ul>\r\nMany psychologists use an\u00a0<strong>integrative psychotherapy\u00a0approach to formulation<\/strong><em><strong>,\u00a0<\/strong><\/em>or the integration of elements from different schools of\u00a0psychotherapy\u00a0in the treatment of a client.\u00a0This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient\u2019s needs. The case formulation may pull from several psychological models and formations, such as those mentioned below:\r\n<ul>\r\n \t<li>A cognitive-behavioral model of formulation described by Jacqueline Persons has seven components: problem list, core beliefs, precipitants and activating situations, origins, working hypothesis, treatment plan, and predicted obstacles to treatment.<\/li>\r\n \t<li>A psychodynamic formulation would consist of a summarizing statement, description of nondynamic factors, description of core psychodynamics using a specific model (such as\u00a0ego psychology,\u00a0object relations, or\u00a0self psychology), and prognostic assessment that identifies the potential areas of\u00a0resistance\u00a0in therapy.<\/li>\r\n \t<li>Behavioral case formulations used in\u00a0applied behavior analysis\u00a0and\u00a0behavior therapy\u00a0are built on a rank list of problem behaviors. Such functional analysis is also used in acceptance and commitment therapy.\u00a0Functional analysis looks at\u00a0<em>setting events<\/em>\u00a0(ecological variables, history effects, and motivating operations);<em>\u00a0antecedents<\/em>;<em> behavior chains<\/em>;\u00a0<em>the problem behavior<\/em>; and the<em> consequences<\/em>, short- and long-term, for the behavior<\/li>\r\n<\/ul>\r\n<div class=\"textbox examples\">\r\n<h3>Watch It<\/h3>\r\nWatch this video to see all the components that go into a case formulation for a client. The video specifically mentions one type of therapy, acceptance and commitment therapy (ACT), but the concepts apply generally to all types of psychotherapy.\r\n\r\n<iframe src=\"\/\/plugin.3playmedia.com\/show?mf=5572151&amp;p3sdk_version=1.10.1&amp;p=20361&amp;pt=375&amp;video_id=NOKCHeEyS9E&amp;video_target=tpm-plugin-3rxulcjq-NOKCHeEyS9E\" width=\"800px\" height=\"450px\" frameborder=\"0\" marginwidth=\"0px\" marginheight=\"0px\"><\/iframe>\r\n\r\nYou can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/ACTCaseConceptualization_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for \"ACT Case Conceptualization: Assessing the 6 Core Processes\" here (opens in new window)<\/a>.\r\n\r\n<\/div>\r\n<h3>Cultural Formulation<\/h3>\r\nA <strong>c<\/strong><strong>ultural formulation<\/strong> is the systematic review of a person's\u00a0cultural\u00a0background and the role of\u00a0culture\u00a0in the manifestation of symptoms and dysfunction. It is argued that a cultural perspective can help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world.\u00a0The <em>DSM-5<\/em> includes a <strong>Cultural Formulation Interview<\/strong> that aims to help clinicians contextualize diagnostic assessment. A related approach to cultural assessment involves cultural consultation that works with interpreters and cultural brokers to develop a cultural formulation and treatment plan that can assist clinicians.\r\n\r\n<b>Cross-cultural psychiatry<\/b>\u00a0(also known as ethnopsychiatry, transcultural psychiatry, or\u00a0cultural psychiatry) is a branch of\u00a0psychiatry\u00a0concerned with the\u00a0cultural\u00a0context of\u00a0mental disorders\u00a0and the challenges of addressing\u00a0ethnic\u00a0diversity in psychiatric services.\u00a0It looks at whether psychiatric classifications of disorders are appropriate to different cultures or ethnic groups. It often argues that psychiatric illnesses represent social constructs as well as genuine medical conditions, and as such have social uses peculiar to the social groups in which they are created and legitimized. It studies psychiatric classifications in different cultures, whether informal (e.g., category terms used in different languages) or formal (for example the World Health Organization\u2019s\u00a0<em>ICD<\/em>, the\u00a0American Psychiatric Association\u2019s\u00a0<em>DSM<\/em>, or the\u00a0Chinese Society of Psychiatry\u2019s\u00a0<em>CCMD<\/em>).\u00a0The field has increasingly had to address the process of\u00a0globalization.\u00a0It is said every city has a different culture and that the urban environment, and how people adapt or struggle to adapt to it, can play a crucial role in the onset or worsening of mental illness.\r\n\r\nReflecting advances in medical anthropology, the <em>DSM-5<\/em> replaced the term\u00a0<strong>culture-bound syndrome<\/strong>\u00a0(or\u00a0folk illness\u2014a combination of psychiatric and somatic\u00a0symptoms\u00a0that are considered to be a recognizable disease only within a specific society or\u00a0culture) with a set of terms covering cultural concepts of distress: cultural syndromes (which may not be bound to a specific culture but circulate across cultures), cultural idioms of distress (local modes of expressing suffering that may not be syndromes), causal explanations (that attribute symptoms or suffering to specific causal factors rooted in local ontologies), and folk diagnostic categories (which may be part of ethnomedical systems and healing practices).\r\n<div>\r\n<div class=\"textbox learning-objectives\">\r\n<h3>dig deeper: Dhat Syndrome<\/h3>\r\nOne argument to support the concept of culture-bound syndromes comes from research on <em>dhat syndrome<\/em>, as it has been specified as a culture-bound syndrome specific to the culture of the Indian subcontinent. The <em>DSM-4<\/em> listed it as a folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns associated with the discharge of semen, whitish discoloration of the urine, and feelings of weakness and exhaustion. Similar to\u00a0<i>jiryan<\/i>\u00a0(India),\u00a0<i>sukra prameha<\/i>\u00a0(Sri Lanka), and\u00a0<i>shen-k'uei<\/i>\u00a0(China), <em>d<\/em><i>hat syndrome<\/i>\u00a0in the <em>DSM-5<\/em> is listed as a term that was coined in South Asia little more than half a century ago to account for common clinical presentations of young male patients who attributed their various symptoms to semen loss. Despite the name, it is not a discrete syndrome but rather a cultural explanation of distress for patients who refer to diverse symptoms, such as anxiety, fatigue, weakness, weight loss, impotence, other multiple somatic complaints, and depressive mood. The cardinal feature is anxiety and distress about the loss of\u00a0<i>dhat<\/i>\u00a0in the absence of any identifiable physiological dysfunction.\r\n\r\nResearch in health care settings has yielded diverse estimates of the syndrome's prevalence (e.g., 64% of men attending psychiatric clinics in India for sexual complaints; 30% of men attending general clinics in Pakistan).\u00a0<span style=\"font-size: 1rem; font-weight: normal; text-align: initial; color: #373d3f;\">Related conditions in <em>DSM-5<\/em> are major depressive disorder, persistent depressive disorder, generalized anxiety disorder, somatic symptom disorder, illness anxiety disorder, erectile disorder, early (premature) ejaculation, and other specified or unspecified sexual dysfunction.\u00a0[footnote]Deb, K. S., &amp; Balhara, Y. P. (2013). Dhat syndrome: a review of the world literature. Indian journal of psychological medicine, 35(4), 326\u2013331. https:\/\/doi.org\/10.4103\/0253-7176.122219[\/footnote]\u00a0<\/span>\r\n\r\n<\/div>\r\n<div class=\"textbox key-takeaways\">\r\n<h3>Think it over<\/h3>\r\n<span style=\"font-size: 1em;\">Cultural influence has been shown to influence the appearance of psychiatric disorders. In the context of psychiatric disorders, cultural influence is present at multiple levels. First, culture and society shape the meanings and expressions people give to various emotions. Second, cultural factors determine which symptoms or signs are normal and abnormal. Third, culture helps define what compromises health and illness. Lastly, it shapes the illness behavior and help-seeking behavior. Overall, cultural influence on psychiatric disorders include conditions other than culture-bound disorders.\u00a0<\/span>The ongoing question about culture-bound syndrome continues as researchers ask themselves, \u201cDoes culture impact only the culture-bound syndrome?\u201d\r\n\r\n<\/div>\r\n<h2><span style=\"font-size: 1.15em; font-weight: 600;\">Planning the Treatment<\/span><\/h2>\r\n<\/div>\r\nFollowing an initial assessment, the client or patient and therapist come to an agreement called the <strong>treatment plan<\/strong>. This is a type of contract that specifies the goals of treatment; treatment procedures; and a regular schedule for the time, place, and duration of their treatment sessions. Sometimes this treatment contract is written down explicitly, but more often it is discussed between the individual seeking therapy and therapist.[footnote]<span style=\"font-size: 1em;\">\u201cWhat Is Psychotherapy?\u201d <\/span><em style=\"font-size: 1em;\">American Psychological Association<\/em><span style=\"font-size: 1em;\">. <\/span><a style=\"font-size: 1em;\" href=\"https:\/\/www.apa.org\/ptsd-guideline\/patients-and-families\/psychotherapy\">https:\/\/www.apa.org\/ptsd-guideline\/patients-and-families\/psychotherapy<\/a>[\/footnote] Services\u00a0are based in\u00a0psychiatric hospitals\u00a0or in the\u00a0community. Determining the treatment site (most often\u00a0private therapist\u2019s outpatient clinic or office) is an important part of planning treatment. Community mental health centers (CMHCs) provide for community-based care as an alternative to institutionalization. At these centers, patients can be treated while working and living at home.\r\n\r\nThe importance of the\u00a0<strong>therapeutic<\/strong> <strong>relationship<\/strong>, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy.\u00a0<b>Psychotherapy<\/b>\u00a0focuses on the use of\u00a0psychological\u00a0methods, particularly when based on regular\u00a0personal interaction\u00a0with adults, to help a person change behavior and overcome problems in desired ways. Psychotherapists may be\u00a0mental health professionals\u00a0such as psychiatrists, psychologists, mental health nurses, clinical social workers, marriage and family therapists, or professional counselors. Psychotherapy aims to improve an individual's\u00a0well-being\u00a0and\u00a0mental health; to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions; and to improve relationships and\u00a0social skills. There is also a range of psychotherapies designed for children and adolescents, which typically involve play. Certain psychotherapies are considered\u00a0evidence-based\u00a0for treating diagnosed\u00a0mental disorders. Others have been criticized as\u00a0pseudoscience. There are over a thousand different psychotherapy techniques, some being minor variations, while others are based on very different conceptions of psychology,\u00a0ethics\u00a0(how to behave professionally), or techniques. Most involve one-to-one sessions between the client and therapist, but some are conducted with\u00a0groups,\u00a0including\u00a0families.\r\n\r\n<span style=\"font-size: 1em; text-align: initial;\">In practice, clinical and counseling psychologists work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organizations, schools, businesses, and non-profit agencies.\u00a0<\/span><span style=\"font-size: 1em;\">Other than p<\/span><span style=\"font-size: 1em;\">roviding psychological treatment (psychotherapy), <strong>c<\/strong><\/span><strong>linical and counseling psychologists<\/strong>\u00a0can offer a range of professional services, including\u00a0<span style=\"font-size: 1em;\">a<\/span><span style=\"font-size: 1em;\">dministering and interpreting psychological assessment and testing, and p<\/span><span style=\"font-size: 1em;\">roviding expert testimony (forensics).\u00a0<\/span>\r\n\r\nAlthough clinical and counseling psychologists and psychiatrists share the same fundamental aim\u2014the alleviation of mental distress\u2014their training, outlook, and methodologies are often different. Perhaps the most significant difference is that\u00a0<strong>psychiatrists<\/strong>\u00a0are licensed\u00a0physicians, and, as such, psychiatrists are apt to use the\u00a0medical model\u00a0to assess mental health problems and to also employ\u00a0psychotropic medications\u00a0as a method of addressing mental health problems.\u00a0Psychologists generally do not prescribe medication, although in some jurisdictions they do have prescription privileges. In five U.S. states (New Mexico, Louisiana, Illinois, Iowa, and Idaho), psychologists with post-doctoral clinical psychopharmacology training have been granted\u00a0prescriptive authority\u00a0for mental health disorders.\u00a0Clinical and counseling psychologists receive extensive training in psychological test administration, scoring, interpretation, and reporting, while psychiatrists are not trained in psychological testing.\r\n<h3>Goals of Treatment<\/h3>\r\nTherapy includes immediate, short-term, and long-term goal setting. Goals are an essential part of the treatment plan as they help a client work towards cognitive and behavioral changes. For example, a therapist may use the SMART goals approach by setting goals that are specific, measurable, achievable, realistic, and time-limited.\r\n<ul>\r\n \t<li><b>S<\/b>pecific\u2014The goal is to be as clear as possible, such as setting a goal to reduce social anxiety levels so that a client can eat lunch with coworkers by the end of the month.<\/li>\r\n \t<li><b>M<\/b>easurable\u2014The goal should be something you can measure, such as tallying up the number of social interactions a client has, or reducing feelings of anxiety from a 9\/10 level to a 4\/10 level.<\/li>\r\n \t<li><b>A<\/b>chievable\u2014The goals should be feasible and within reach. If a person has severe social anxiety, having them host a party or go out every night for a week would be difficult short-term goals that are likely unachievable.<\/li>\r\n \t<li><b>R<\/b>ealistic and Resourced\u2014Is the goal realistic and possible given the time and resources available to you?<\/li>\r\n \t<li><b>T<\/b>ime-limited\u2014The goal should have a specific time frame when it will be reached.[footnote]wikiHow. \u201cHow to Write a Mental Health Treatment Plan.\u201d Accessed December 9, 2020. https:\/\/www.wikihow.com\/Write-a-Mental-Health-Treatment-Plan.[\/footnote]<\/li>\r\n<\/ul>\r\n<div>\r\n<div class=\"textbox exercises\">\r\n<h3>Link to Learning<\/h3>\r\n<a href=\"https:\/\/www.apa.org\/topics\/psychotherapy\/understanding#:~:text=Psychotherapy%20is%20a%20collaborative%20treatment,an%20individual%20and%20a%20psychologist.&amp;text=You%20and%20your%20psychologist%20will,you%20from%20feeling%20your%20best.\" target=\"_blank\" rel=\"noopener\">This APA article, \"Understanding Psychotherapy and How It Works<\/a>\" provides a good introductory overview of what you can expect during psychotherapy.\r\n\r\n<\/div>\r\n<\/div>\r\n<div id=\"post-397\" class=\"standard post-397 chapter type-chapter status-publish hentry\">\r\n<div class=\"entry-content\"><section id=\"fs-idm146412176\" class=\"summary focusable focusable\">\r\n<h2>Evidence-Based Practice and Ethical Duties<\/h2>\r\n<strong>Professional competence<\/strong>\u2014the ability to accurately assess problems, diagnose psychological disorders, recommend an appropriate course of treatment, and successfully carry out that treatment\u2014varies depending on the degree to which the clinician keeps up to date with the latest research and effectively evaluates the evidence. The APA requires that clinicians be trained in <strong>evidence-based practice (EBP)<\/strong> to be equipped to appraise the range of evidence regarding the efficacy of different forms of psychotherapy, to recognize the strengths and limitations of clinical intuition, and to understand the importance of patient preferences and values as well as the relevance of the socio-cultural context in treating clients.\r\n\r\nWhy does evidence-based practice (EBP) matter for the ethical practice of psychological treatments? Evidence carries ethical imperatives. Both the decision about what is considered to be beneficial in psychotherapy, and the current paucity of research regarding the potential negative effects of psychological treatments, carry ethical implications. It is argued that the failure to pay attention to psychotherapy research effectively risks undermining key requisites included in professional codes of practice for clinical psychology, psychiatry, social work, and allied fields. First, evidence-based practice (EBP) bears repercussions for the clinician\u2019s duty of professional competence, or the responsibility to acquire and apply accurate knowledge. Second, EBP is relevant to the duty to respect patient autonomy\u2014namely, the patient\u2019s right to make informed decisions concerning their treatment plans.\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/9daf9c92-afad-4454-8fde-8222e3875368\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/a990d52c-3ed4-4523-a61f-4f2a5d25c1ed\r\n\r\nhttps:\/\/assess.lumenlearning.com\/practice\/0b141a6b-c605-4e2e-84e2-d5d20ef472ab\r\n\r\n<\/div>\r\n<div class=\"textbox learning-objectives\">\r\n<h3>Glossary<\/h3>\r\n<div id=\"fs-idm53428592\">\r\n\r\n<strong>client:\u00a0<\/strong>reflects that people in treatment collaborate with those who treat them\r\n\r\n<strong>clinician: <\/strong>health care\u00a0professional who works directly with patients and may diagnose, treat, and otherwise care for patients.\r\n\r\n<strong>clinical and counseling psychologists:\u00a0<\/strong>mental health professional with training in behavioral science who provide direct service to clients\r\n\r\n<strong>c<\/strong><strong>linical formulation<\/strong>\/<strong>case formulation: <\/strong>analyzes the factors that may have influenced the client\u2019s current psychological state\r\n\r\n<strong>c<\/strong><strong>onfidentiality:<\/strong> therapist cannot disclose confidential communications to any third party, unless mandated or permitted by law\r\n\r\n<strong>couples therapy:<\/strong> when two people in an intimate relationship, such as husband and wife, attend counseling together to resolve conflict\r\n\r\n<b>cross-cultural psychiatry<\/b><strong>:<\/strong> a branch of\u00a0psychiatry\u00a0concerned with the\u00a0cultural\u00a0context of\u00a0mental disorders\u00a0and the challenges of addressing\u00a0ethnic\u00a0diversity in psychiatric services\r\n\r\n<strong>culture-bound syndrome:<\/strong>\u00a0a combination of psychiatric and somatic\u00a0symptoms\u00a0that are considered to be a recognizable disease only within a specific society or\u00a0culture\r\n\r\n<strong>cultural formulation: <\/strong>a\u00a0systematic review of a person's\u00a0cultural\u00a0background and the role of\u00a0culture\u00a0in the manifestation of symptoms and dysfunction\r\n\r\n<strong>cultural formulation interview: <\/strong>aims to help clinicians contextualize diagnostic assessment\r\n\r\n<strong>diagnosis:\u00a0<\/strong>refers to t<span style=\"font-size: 1em;\">he identification of the nature and cause of an illness or t<\/span><span style=\"font-size: 1em;\">he identification of the nature and cause of something<\/span>\r\n\r\n<strong>family therapy: <\/strong>special form of group therapy consisting of one or more families\r\n\r\n<strong>group therapy: <\/strong>treatment modality in which five to 10 people with the same issue or concern meet together with a trained clinician\r\n\r\n<strong>individual therapy: <\/strong>treatment modality in which the client and clinician meet one-on-one\r\n\r\n<strong>intake: <\/strong>therapist\u2019s first meeting with the client in which the therapist gathers specific information to address the client\u2019s immediate needs\r\n\r\n<strong>integrative psychotherapy\u00a0approach to formulation:<\/strong> the integration of elements from different schools of\u00a0psychotherapy\u00a0in the treatment of a client\r\n\r\n<b>mental status examination<\/b>\u00a0(<b>MSE<\/b>): a\u00a0structured way of observing and describing a\u00a0patient's psychological functioning at a given point in time under the domains of appearance,\u00a0attitude, behavior, mood, and affect speech,\u00a0thought process, thought content,\u00a0perception,\u00a0cognition, insight, and\u00a0judgment\r\n\r\n<strong>patient:\u00a0<\/strong>any recipient of\u00a0health care\u00a0services performed by\u00a0healthcare professionals\r\n\r\n<strong>psychiatrists:<\/strong>\u00a0licensed\u00a0physicians (MD) with specialized training in diagnosing and treating people with psychological disorders\r\n\r\n<strong>psychologist<\/strong>: health care professional offering psychological services\r\n\r\n<strong>strategic family therapy<\/strong>: when a therapist guides the therapy sessions and develops treatment plans for each family member for specific problems that can be addressed in a short amount of time\r\n\r\n<strong>structural family therapy: <\/strong>therapist examines and discusses with the family the boundaries and structure of the family: who makes the rules, who sleeps in the bed with whom, how decisions are made, and what are the boundaries within the family\r\n\r\n<strong>therapeutic relationship<\/strong>:\u00a0the relationship between a health care professional and a\u00a0client\u00a0(or\u00a0patient)\r\n\r\n<strong>treatment plan: <\/strong>collaborative goal setting\u00a0or\u00a0outline of how therapy takes place\r\n\r\n<\/div>\r\n<\/div>\r\n<\/section><\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul id=\"id_0077421000_001_001824\" class=\"objectives\">\n<li id=\"id_0077421000_001_001829\" class=\"objective\" value=\"4\">Explain the steps and people involved in the diagnostic process, including the case formulation<\/li>\n<\/ul>\n<\/div>\n<p>The word <strong>diagnosis<\/strong> commonly refers to t<span style=\"font-size: 1em;\">he identification of the nature and cause of an illness<\/span><span style=\"font-size: 1em;\">. When a mental health professional diagnoses a client or patient, the first steps can be summarized as gathering information, narrowing down the options, and formulating a diagnostic impression.\u00a0<\/span><\/p>\n<p>The diagnostic process involves gathering relevant information\u00a0from a person\u00a0through a detailed interview that includes finding out the person\u2019s main concerns, their symptoms, and their life history.\u00a0This information includes the results from psychological\u00a0<span style=\"font-size: 1em;\">tests or questionnaires and may include i<\/span><span style=\"font-size: 1rem; text-align: initial;\">nformation obtained from the person\u2019s family and\/or from previous treatment records. Mental health professionals\u00a0<\/span>use this first phase of working with clients before proceeding with the treatment itself. More specifically, before\u00a0<span style=\"font-size: 1em;\">a<\/span><span style=\"font-size: 1em; text-align: initial;\">\u00a0diagnosis is given,\u00a0<\/span>they\u00a0<span style=\"font-size: 1em;\">determine whether the person\u2019s symptoms match the <em>DSM<\/em>\u2019s criteria for a particular mental disorder, and if there is\u00a0<\/span><span style=\"font-size: 1em;\">a significant level of disturbance in the person\u2019s cognitive, emotional, or behavioral functioning.\u00a0<\/span><span style=\"font-size: 1em; text-align: initial;\">\u00a0<\/span><\/p>\n<h2><span id=\"Clients,_survivors,_and_consumers\" class=\"mw-headline\">Clients, Consumers, and Patients<\/span><\/h2>\n<p><span style=\"font-size: 1em; text-align: initial;\">Why all the different terms? <strong>Patient<\/strong> and <strong>client<\/strong> are terms that carry different connotations, often depending on the method of treatment, or treatment site. For many professionals, a <em>patient<\/em>\u00a0is any recipient of\u00a0health care\u00a0services performed by\u00a0healthcare professionals, and <em>c<\/em><\/span><em>lient<\/em>\u00a0reflects that people in treatment collaborate with those who treat them, notably, the <strong>clinician<\/strong>\u2014a\u00a0professional who works directly with patients or clients and may diagnose, treat, and otherwise care for them.\u00a0A term adopted by many users of psychiatric services is <em>consumer<\/em>.&#8221; This term was chosen to eliminate the &#8220;patient&#8221; label and restore the person to an active role as a user or consumer of services.<a class=\"footnote\" title=\"Halpern, L, Trachtman, H. and Duckworth, K. &quot;From Within: A Consumer Perspective on Psychiatric Hospitals,&quot; in Textbook of Hospital Psychiatry, S. Sharfstein, F. Dickerson and J. Oldham eds. American Psychiatric Publishing, 2009, pp. 237\u2013244.\" id=\"return-footnote-1286-1\" href=\"#footnote-1286-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a> The terms\u00a0<i>clients<\/i>\u00a0and\u00a0<i>consumers<\/i>\u00a0imply a much more active role on the part of the individual and therefore imply that\u00a0<span style=\"font-size: 1em;\">h<\/span><span style=\"font-size: 1em;\">ealthcare\u00a0<\/span><span style=\"font-size: 1rem; text-align: initial;\">professionals are not the only ones who have expertise in healthy functioning.<\/span><\/p>\n<h2><span style=\"background-color: #ffffff;\">Diagnostic Procedures<\/span><\/h2>\n<p>The main goal of the information-gathering model is to accurately diagnose, plan treatments, and evaluate treatment effectiveness. The key to diagnosis is gaining as clear a description as possible of a client&#8217;s or patient&#8217;s symptoms. Mental health professionals listen to what the client or patient reports, and they observe quite a number of things, such as\u00a0<span style=\"font-size: 1em;\">behavior and emotional expression<\/span><span style=\"font-size: 1rem; text-align: initial;\">.\u00a0Routine diagnostic practice in mental health services typically involves an interview known as a\u00a0<strong>mental status examination<\/strong>, where evaluations are made of appearance and behavior, self-reported symptoms, mental health history, and current life circumstances.<\/span><\/p>\n<p>We will discuss a variety of assessment tools used by mental health professionals to determine the extent to which these symptoms correspond with the diagnostic criteria of a given disorder. This approach to diagnosis\u00a0is more systematic, and\u00a0allows one to determine\u00a0the exact nature of a client&#8217;s symptoms, the length of time the client has experienced these symptoms, and any associated symptoms.<\/p>\n<h3><strong>Elements of a Diagnosis<\/strong><\/h3>\n<p>By\u00a0<span style=\"font-size: 1em;\">listening to clients as they describe the experience of their symptoms, and following up with <\/span>assessment<span style=\"font-size: 1em;\">\u00a0tools (not always, but often), the mental health professional<\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0begins to formulate the\u00a0<\/span><strong style=\"font-size: 1rem; text-align: initial;\">principal diagnosis<\/strong><span style=\"font-size: 1rem; text-align: initial;\">\u2014or the reason for the visit. This means determining the single diagnosis that is most relevant to the person&#8217;s\u00a0chief complaint\u00a0or need for treatment; this diagnosis will be the main\u00a0focus of clinical attention or treatment.<\/span><\/p>\n<p><span style=\"font-size: 1rem; text-align: initial;\"> After determining the primary reason the individual is seeking professional help, a<\/span>\u00a0<strong>differential diagnosis<\/strong>\u00a0is commonly used. Two different diagnoses can be attached to a patient who is exhibiting symptoms that could fit into either diagnosis. For example, a patient who has been diagnosed with bipolar disorder may also be given a differential diagnosis of borderline personality disorder, given the similarity in the symptoms of both conditions. Where multiple alternatives are possible, this method is akin to the\u00a0process of elimination or ruling out of alternative diagnoses, a crucial step in the diagnostic process.<\/p>\n<p><span style=\"font-size: 1rem; text-align: initial;\">Many patients have additional diagnoses. <strong>C<\/strong><\/span><strong>omorbidity<\/strong>\u00a0refers to the presence of more than one diagnosis occurring in an individual at the same time.\u00a0In the context of mental health, comorbidity often refers to\u00a0disorders\u00a0that are often coexistent with each other, such as\u00a0substance<span style=\"font-size: 1em;\">\u00a0use disorder and\u00a0<\/span><span style=\"text-align: initial;\"><span style=\"font-size: 1rem;\">depression (the most common comorbidities involve the concurrence of\u00a0<\/span><span style=\"font-size: 1em;\">substance<span style=\"font-size: 1em;\">\u00a0use disorders\u00a0<\/span><\/span><span style=\"font-size: 1rem;\">with other mental disorders). Multiple diagnoses are usually presented in a hierarchy\u00a0descending from the condition of most significance to that of the least concern.<\/span><\/span><\/p>\n<h2>The Case Formulation<\/h2>\n<div id=\"post-230\" class=\"standard post-230 chapter type-chapter status-publish hentry\">\n<div class=\"entry-content\">\n<p>Once the mental health professional makes a formal diagnosis, they then analyze the factors that may have influenced the patient or client\u2019s current psychological state. A\u00a0<b>clinical formulation<\/b>, also known as\u00a0case formulation or case conceptualization,\u00a0is that analysis, or a theoretically based explanation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems (e.g., background history, presenting concerns, and manifestation and progression of behavioral signs and symptoms over time), and is considered an adjunct or alternative approach to the more categorical approach of psychiatric\u00a0diagnosis.\u00a0These formulations are used to communicate a\u00a0hypothesis\u00a0and provide a framework for developing the most suitable treatment approach, rather than labels or diagnostic codes. It gives a rich description of the client\u2019s personal history and pieces together how the disorder evolved. It is most commonly used by\u00a0clinical psychologists\u00a0and\u00a0psychiatrists\u00a0and is deemed to be a core component of these professions.\u00a0Mental health nurses and social workers may also use formulations. As mental health professionals, we need to consider both the\u00a0purpose of our communication and the audience for that communication. As\u00a0professionals, we must also consider the potential misuse of documents by others,\u00a0which will influence the way that we present our case formulation.<\/p>\n<h2><span id=\"Types_of_formulation\" class=\"mw-headline\">Types of Formulation<\/span><\/h2>\n<p>Different psychological schools or models utilize clinical formulations, including cognitive-behavioral therapy\u00a0(CBT) and related therapies:\u00a0systemic therapy,\u00a0psychodynamic therapy,\u00a0and\u00a0applied behavior analysis.\u00a0The structure and content of a clinical formulation is determined by the psychological model (which we will examine more closely in another module). Most systems of formulation contain the following broad categories of information:<\/p>\n<ul>\n<li>symptoms and problems<\/li>\n<li>precipitating stressors or events<\/li>\n<li>predisposing life events or stressors<\/li>\n<li>an explanatory mechanism that links the preceding categories together<\/li>\n<li>a description of the precipitants and maintaining influences of the person\u2019s problems<\/li>\n<\/ul>\n<p>Many psychologists use an\u00a0<strong>integrative psychotherapy\u00a0approach to formulation<\/strong><em><strong>,\u00a0<\/strong><\/em>or the integration of elements from different schools of\u00a0psychotherapy\u00a0in the treatment of a client.\u00a0This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient\u2019s needs. The case formulation may pull from several psychological models and formations, such as those mentioned below:<\/p>\n<ul>\n<li>A cognitive-behavioral model of formulation described by Jacqueline Persons has seven components: problem list, core beliefs, precipitants and activating situations, origins, working hypothesis, treatment plan, and predicted obstacles to treatment.<\/li>\n<li>A psychodynamic formulation would consist of a summarizing statement, description of nondynamic factors, description of core psychodynamics using a specific model (such as\u00a0ego psychology,\u00a0object relations, or\u00a0self psychology), and prognostic assessment that identifies the potential areas of\u00a0resistance\u00a0in therapy.<\/li>\n<li>Behavioral case formulations used in\u00a0applied behavior analysis\u00a0and\u00a0behavior therapy\u00a0are built on a rank list of problem behaviors. Such functional analysis is also used in acceptance and commitment therapy.\u00a0Functional analysis looks at\u00a0<em>setting events<\/em>\u00a0(ecological variables, history effects, and motivating operations);<em>\u00a0antecedents<\/em>;<em> behavior chains<\/em>;\u00a0<em>the problem behavior<\/em>; and the<em> consequences<\/em>, short- and long-term, for the behavior<\/li>\n<\/ul>\n<div class=\"textbox examples\">\n<h3>Watch It<\/h3>\n<p>Watch this video to see all the components that go into a case formulation for a client. The video specifically mentions one type of therapy, acceptance and commitment therapy (ACT), but the concepts apply generally to all types of psychotherapy.<\/p>\n<p><iframe loading=\"lazy\" src=\"\/\/plugin.3playmedia.com\/show?mf=5572151&amp;p3sdk_version=1.10.1&amp;p=20361&amp;pt=375&amp;video_id=NOKCHeEyS9E&amp;video_target=tpm-plugin-3rxulcjq-NOKCHeEyS9E\" width=\"800px\" height=\"450px\" frameborder=\"0\" marginwidth=\"0px\" marginheight=\"0px\"><\/iframe><\/p>\n<p>You can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/ACTCaseConceptualization_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for &#8220;ACT Case Conceptualization: Assessing the 6 Core Processes&#8221; here (opens in new window)<\/a>.<\/p>\n<\/div>\n<h3>Cultural Formulation<\/h3>\n<p>A <strong>c<\/strong><strong>ultural formulation<\/strong> is the systematic review of a person&#8217;s\u00a0cultural\u00a0background and the role of\u00a0culture\u00a0in the manifestation of symptoms and dysfunction. It is argued that a cultural perspective can help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world.\u00a0The <em>DSM-5<\/em> includes a <strong>Cultural Formulation Interview<\/strong> that aims to help clinicians contextualize diagnostic assessment. A related approach to cultural assessment involves cultural consultation that works with interpreters and cultural brokers to develop a cultural formulation and treatment plan that can assist clinicians.<\/p>\n<p><b>Cross-cultural psychiatry<\/b>\u00a0(also known as ethnopsychiatry, transcultural psychiatry, or\u00a0cultural psychiatry) is a branch of\u00a0psychiatry\u00a0concerned with the\u00a0cultural\u00a0context of\u00a0mental disorders\u00a0and the challenges of addressing\u00a0ethnic\u00a0diversity in psychiatric services.\u00a0It looks at whether psychiatric classifications of disorders are appropriate to different cultures or ethnic groups. It often argues that psychiatric illnesses represent social constructs as well as genuine medical conditions, and as such have social uses peculiar to the social groups in which they are created and legitimized. It studies psychiatric classifications in different cultures, whether informal (e.g., category terms used in different languages) or formal (for example the World Health Organization\u2019s\u00a0<em>ICD<\/em>, the\u00a0American Psychiatric Association\u2019s\u00a0<em>DSM<\/em>, or the\u00a0Chinese Society of Psychiatry\u2019s\u00a0<em>CCMD<\/em>).\u00a0The field has increasingly had to address the process of\u00a0globalization.\u00a0It is said every city has a different culture and that the urban environment, and how people adapt or struggle to adapt to it, can play a crucial role in the onset or worsening of mental illness.<\/p>\n<p>Reflecting advances in medical anthropology, the <em>DSM-5<\/em> replaced the term\u00a0<strong>culture-bound syndrome<\/strong>\u00a0(or\u00a0folk illness\u2014a combination of psychiatric and somatic\u00a0symptoms\u00a0that are considered to be a recognizable disease only within a specific society or\u00a0culture) with a set of terms covering cultural concepts of distress: cultural syndromes (which may not be bound to a specific culture but circulate across cultures), cultural idioms of distress (local modes of expressing suffering that may not be syndromes), causal explanations (that attribute symptoms or suffering to specific causal factors rooted in local ontologies), and folk diagnostic categories (which may be part of ethnomedical systems and healing practices).<\/p>\n<div>\n<div class=\"textbox learning-objectives\">\n<h3>dig deeper: Dhat Syndrome<\/h3>\n<p>One argument to support the concept of culture-bound syndromes comes from research on <em>dhat syndrome<\/em>, as it has been specified as a culture-bound syndrome specific to the culture of the Indian subcontinent. The <em>DSM-4<\/em> listed it as a folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns associated with the discharge of semen, whitish discoloration of the urine, and feelings of weakness and exhaustion. Similar to\u00a0<i>jiryan<\/i>\u00a0(India),\u00a0<i>sukra prameha<\/i>\u00a0(Sri Lanka), and\u00a0<i>shen-k&#8217;uei<\/i>\u00a0(China), <em>d<\/em><i>hat syndrome<\/i>\u00a0in the <em>DSM-5<\/em> is listed as a term that was coined in South Asia little more than half a century ago to account for common clinical presentations of young male patients who attributed their various symptoms to semen loss. Despite the name, it is not a discrete syndrome but rather a cultural explanation of distress for patients who refer to diverse symptoms, such as anxiety, fatigue, weakness, weight loss, impotence, other multiple somatic complaints, and depressive mood. The cardinal feature is anxiety and distress about the loss of\u00a0<i>dhat<\/i>\u00a0in the absence of any identifiable physiological dysfunction.<\/p>\n<p>Research in health care settings has yielded diverse estimates of the syndrome&#8217;s prevalence (e.g., 64% of men attending psychiatric clinics in India for sexual complaints; 30% of men attending general clinics in Pakistan).\u00a0<span style=\"font-size: 1rem; font-weight: normal; text-align: initial; color: #373d3f;\">Related conditions in <em>DSM-5<\/em> are major depressive disorder, persistent depressive disorder, generalized anxiety disorder, somatic symptom disorder, illness anxiety disorder, erectile disorder, early (premature) ejaculation, and other specified or unspecified sexual dysfunction.\u00a0<a class=\"footnote\" title=\"Deb, K. S., &amp; Balhara, Y. P. (2013). Dhat syndrome: a review of the world literature. Indian journal of psychological medicine, 35(4), 326\u2013331. https:\/\/doi.org\/10.4103\/0253-7176.122219\" id=\"return-footnote-1286-2\" href=\"#footnote-1286-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a>\u00a0<\/span><\/p>\n<\/div>\n<div class=\"textbox key-takeaways\">\n<h3>Think it over<\/h3>\n<p><span style=\"font-size: 1em;\">Cultural influence has been shown to influence the appearance of psychiatric disorders. In the context of psychiatric disorders, cultural influence is present at multiple levels. First, culture and society shape the meanings and expressions people give to various emotions. Second, cultural factors determine which symptoms or signs are normal and abnormal. Third, culture helps define what compromises health and illness. Lastly, it shapes the illness behavior and help-seeking behavior. Overall, cultural influence on psychiatric disorders include conditions other than culture-bound disorders.\u00a0<\/span>The ongoing question about culture-bound syndrome continues as researchers ask themselves, \u201cDoes culture impact only the culture-bound syndrome?\u201d<\/p>\n<\/div>\n<h2><span style=\"font-size: 1.15em; font-weight: 600;\">Planning the Treatment<\/span><\/h2>\n<\/div>\n<p>Following an initial assessment, the client or patient and therapist come to an agreement called the <strong>treatment plan<\/strong>. This is a type of contract that specifies the goals of treatment; treatment procedures; and a regular schedule for the time, place, and duration of their treatment sessions. Sometimes this treatment contract is written down explicitly, but more often it is discussed between the individual seeking therapy and therapist.<a class=\"footnote\" title=\"\u201cWhat Is Psychotherapy?\u201d American Psychological Association. https:\/\/www.apa.org\/ptsd-guideline\/patients-and-families\/psychotherapy\" id=\"return-footnote-1286-3\" href=\"#footnote-1286-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a> Services\u00a0are based in\u00a0psychiatric hospitals\u00a0or in the\u00a0community. Determining the treatment site (most often\u00a0private therapist\u2019s outpatient clinic or office) is an important part of planning treatment. Community mental health centers (CMHCs) provide for community-based care as an alternative to institutionalization. At these centers, patients can be treated while working and living at home.<\/p>\n<p>The importance of the\u00a0<strong>therapeutic<\/strong> <strong>relationship<\/strong>, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy.\u00a0<b>Psychotherapy<\/b>\u00a0focuses on the use of\u00a0psychological\u00a0methods, particularly when based on regular\u00a0personal interaction\u00a0with adults, to help a person change behavior and overcome problems in desired ways. Psychotherapists may be\u00a0mental health professionals\u00a0such as psychiatrists, psychologists, mental health nurses, clinical social workers, marriage and family therapists, or professional counselors. Psychotherapy aims to improve an individual&#8217;s\u00a0well-being\u00a0and\u00a0mental health; to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions; and to improve relationships and\u00a0social skills. There is also a range of psychotherapies designed for children and adolescents, which typically involve play. Certain psychotherapies are considered\u00a0evidence-based\u00a0for treating diagnosed\u00a0mental disorders. Others have been criticized as\u00a0pseudoscience. There are over a thousand different psychotherapy techniques, some being minor variations, while others are based on very different conceptions of psychology,\u00a0ethics\u00a0(how to behave professionally), or techniques. Most involve one-to-one sessions between the client and therapist, but some are conducted with\u00a0groups,\u00a0including\u00a0families.<\/p>\n<p><span style=\"font-size: 1em; text-align: initial;\">In practice, clinical and counseling psychologists work with individuals, couples, families, or groups in a variety of settings, including private practices, hospitals, mental health organizations, schools, businesses, and non-profit agencies.\u00a0<\/span><span style=\"font-size: 1em;\">Other than p<\/span><span style=\"font-size: 1em;\">roviding psychological treatment (psychotherapy), <strong>c<\/strong><\/span><strong>linical and counseling psychologists<\/strong>\u00a0can offer a range of professional services, including\u00a0<span style=\"font-size: 1em;\">a<\/span><span style=\"font-size: 1em;\">dministering and interpreting psychological assessment and testing, and p<\/span><span style=\"font-size: 1em;\">roviding expert testimony (forensics).\u00a0<\/span><\/p>\n<p>Although clinical and counseling psychologists and psychiatrists share the same fundamental aim\u2014the alleviation of mental distress\u2014their training, outlook, and methodologies are often different. Perhaps the most significant difference is that\u00a0<strong>psychiatrists<\/strong>\u00a0are licensed\u00a0physicians, and, as such, psychiatrists are apt to use the\u00a0medical model\u00a0to assess mental health problems and to also employ\u00a0psychotropic medications\u00a0as a method of addressing mental health problems.\u00a0Psychologists generally do not prescribe medication, although in some jurisdictions they do have prescription privileges. In five U.S. states (New Mexico, Louisiana, Illinois, Iowa, and Idaho), psychologists with post-doctoral clinical psychopharmacology training have been granted\u00a0prescriptive authority\u00a0for mental health disorders.\u00a0Clinical and counseling psychologists receive extensive training in psychological test administration, scoring, interpretation, and reporting, while psychiatrists are not trained in psychological testing.<\/p>\n<h3>Goals of Treatment<\/h3>\n<p>Therapy includes immediate, short-term, and long-term goal setting. Goals are an essential part of the treatment plan as they help a client work towards cognitive and behavioral changes. For example, a therapist may use the SMART goals approach by setting goals that are specific, measurable, achievable, realistic, and time-limited.<\/p>\n<ul>\n<li><b>S<\/b>pecific\u2014The goal is to be as clear as possible, such as setting a goal to reduce social anxiety levels so that a client can eat lunch with coworkers by the end of the month.<\/li>\n<li><b>M<\/b>easurable\u2014The goal should be something you can measure, such as tallying up the number of social interactions a client has, or reducing feelings of anxiety from a 9\/10 level to a 4\/10 level.<\/li>\n<li><b>A<\/b>chievable\u2014The goals should be feasible and within reach. If a person has severe social anxiety, having them host a party or go out every night for a week would be difficult short-term goals that are likely unachievable.<\/li>\n<li><b>R<\/b>ealistic and Resourced\u2014Is the goal realistic and possible given the time and resources available to you?<\/li>\n<li><b>T<\/b>ime-limited\u2014The goal should have a specific time frame when it will be reached.<a class=\"footnote\" title=\"wikiHow. \u201cHow to Write a Mental Health Treatment Plan.\u201d Accessed December 9, 2020. https:\/\/www.wikihow.com\/Write-a-Mental-Health-Treatment-Plan.\" id=\"return-footnote-1286-4\" href=\"#footnote-1286-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><\/li>\n<\/ul>\n<div>\n<div class=\"textbox exercises\">\n<h3>Link to Learning<\/h3>\n<p><a href=\"https:\/\/www.apa.org\/topics\/psychotherapy\/understanding#:~:text=Psychotherapy%20is%20a%20collaborative%20treatment,an%20individual%20and%20a%20psychologist.&amp;text=You%20and%20your%20psychologist%20will,you%20from%20feeling%20your%20best.\" target=\"_blank\" rel=\"noopener\">This APA article, &#8220;Understanding Psychotherapy and How It Works<\/a>&#8221; provides a good introductory overview of what you can expect during psychotherapy.<\/p>\n<\/div>\n<\/div>\n<div id=\"post-397\" class=\"standard post-397 chapter type-chapter status-publish hentry\">\n<div class=\"entry-content\">\n<section id=\"fs-idm146412176\" class=\"summary focusable focusable\">\n<h2>Evidence-Based Practice and Ethical Duties<\/h2>\n<p><strong>Professional competence<\/strong>\u2014the ability to accurately assess problems, diagnose psychological disorders, recommend an appropriate course of treatment, and successfully carry out that treatment\u2014varies depending on the degree to which the clinician keeps up to date with the latest research and effectively evaluates the evidence. The APA requires that clinicians be trained in <strong>evidence-based practice (EBP)<\/strong> to be equipped to appraise the range of evidence regarding the efficacy of different forms of psychotherapy, to recognize the strengths and limitations of clinical intuition, and to understand the importance of patient preferences and values as well as the relevance of the socio-cultural context in treating clients.<\/p>\n<p>Why does evidence-based practice (EBP) matter for the ethical practice of psychological treatments? Evidence carries ethical imperatives. Both the decision about what is considered to be beneficial in psychotherapy, and the current paucity of research regarding the potential negative effects of psychological treatments, carry ethical implications. It is argued that the failure to pay attention to psychotherapy research effectively risks undermining key requisites included in professional codes of practice for clinical psychology, psychiatry, social work, and allied fields. First, evidence-based practice (EBP) bears repercussions for the clinician\u2019s duty of professional competence, or the responsibility to acquire and apply accurate knowledge. Second, EBP is relevant to the duty to respect patient autonomy\u2014namely, the patient\u2019s right to make informed decisions concerning their treatment plans.<\/p>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_9daf9c92-afad-4454-8fde-8222e3875368\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/9daf9c92-afad-4454-8fde-8222e3875368?iframe_resize_id=assessment_practice_id_9daf9c92-afad-4454-8fde-8222e3875368\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_a990d52c-3ed4-4523-a61f-4f2a5d25c1ed\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/a990d52c-3ed4-4523-a61f-4f2a5d25c1ed?iframe_resize_id=assessment_practice_id_a990d52c-3ed4-4523-a61f-4f2a5d25c1ed\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<p>\t<iframe id=\"assessment_practice_0b141a6b-c605-4e2e-84e2-d5d20ef472ab\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/0b141a6b-c605-4e2e-84e2-d5d20ef472ab?iframe_resize_id=assessment_practice_id_0b141a6b-c605-4e2e-84e2-d5d20ef472ab\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<div class=\"textbox learning-objectives\">\n<h3>Glossary<\/h3>\n<div id=\"fs-idm53428592\">\n<p><strong>client:\u00a0<\/strong>reflects that people in treatment collaborate with those who treat them<\/p>\n<p><strong>clinician: <\/strong>health care\u00a0professional who works directly with patients and may diagnose, treat, and otherwise care for patients.<\/p>\n<p><strong>clinical and counseling psychologists:\u00a0<\/strong>mental health professional with training in behavioral science who provide direct service to clients<\/p>\n<p><strong>c<\/strong><strong>linical formulation<\/strong>\/<strong>case formulation: <\/strong>analyzes the factors that may have influenced the client\u2019s current psychological state<\/p>\n<p><strong>c<\/strong><strong>onfidentiality:<\/strong> therapist cannot disclose confidential communications to any third party, unless mandated or permitted by law<\/p>\n<p><strong>couples therapy:<\/strong> when two people in an intimate relationship, such as husband and wife, attend counseling together to resolve conflict<\/p>\n<p><b>cross-cultural psychiatry<\/b><strong>:<\/strong> a branch of\u00a0psychiatry\u00a0concerned with the\u00a0cultural\u00a0context of\u00a0mental disorders\u00a0and the challenges of addressing\u00a0ethnic\u00a0diversity in psychiatric services<\/p>\n<p><strong>culture-bound syndrome:<\/strong>\u00a0a combination of psychiatric and somatic\u00a0symptoms\u00a0that are considered to be a recognizable disease only within a specific society or\u00a0culture<\/p>\n<p><strong>cultural formulation: <\/strong>a\u00a0systematic review of a person&#8217;s\u00a0cultural\u00a0background and the role of\u00a0culture\u00a0in the manifestation of symptoms and dysfunction<\/p>\n<p><strong>cultural formulation interview: <\/strong>aims to help clinicians contextualize diagnostic assessment<\/p>\n<p><strong>diagnosis:\u00a0<\/strong>refers to t<span style=\"font-size: 1em;\">he identification of the nature and cause of an illness or t<\/span><span style=\"font-size: 1em;\">he identification of the nature and cause of something<\/span><\/p>\n<p><strong>family therapy: <\/strong>special form of group therapy consisting of one or more families<\/p>\n<p><strong>group therapy: <\/strong>treatment modality in which five to 10 people with the same issue or concern meet together with a trained clinician<\/p>\n<p><strong>individual therapy: <\/strong>treatment modality in which the client and clinician meet one-on-one<\/p>\n<p><strong>intake: <\/strong>therapist\u2019s first meeting with the client in which the therapist gathers specific information to address the client\u2019s immediate needs<\/p>\n<p><strong>integrative psychotherapy\u00a0approach to formulation:<\/strong> the integration of elements from different schools of\u00a0psychotherapy\u00a0in the treatment of a client<\/p>\n<p><b>mental status examination<\/b>\u00a0(<b>MSE<\/b>): a\u00a0structured way of observing and describing a\u00a0patient&#8217;s psychological functioning at a given point in time under the domains of appearance,\u00a0attitude, behavior, mood, and affect speech,\u00a0thought process, thought content,\u00a0perception,\u00a0cognition, insight, and\u00a0judgment<\/p>\n<p><strong>patient:\u00a0<\/strong>any recipient of\u00a0health care\u00a0services performed by\u00a0healthcare professionals<\/p>\n<p><strong>psychiatrists:<\/strong>\u00a0licensed\u00a0physicians (MD) with specialized training in diagnosing and treating people with psychological disorders<\/p>\n<p><strong>psychologist<\/strong>: health care professional offering psychological services<\/p>\n<p><strong>strategic family therapy<\/strong>: when a therapist guides the therapy sessions and develops treatment plans for each family member for specific problems that can be addressed in a short amount of time<\/p>\n<p><strong>structural family therapy: <\/strong>therapist examines and discusses with the family the boundaries and structure of the family: who makes the rules, who sleeps in the bed with whom, how decisions are made, and what are the boundaries within the family<\/p>\n<p><strong>therapeutic relationship<\/strong>:\u00a0the relationship between a health care professional and a\u00a0client\u00a0(or\u00a0patient)<\/p>\n<p><strong>treatment plan: <\/strong>collaborative goal setting\u00a0or\u00a0outline of how therapy takes place<\/p>\n<\/div>\n<\/div>\n<\/section>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-1286\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>DSM. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Diagnostic_and_Statistical_Manual_of_Mental_Disorders#cite_note-93\">https:\/\/en.wikipedia.org\/wiki\/Diagnostic_and_Statistical_Manual_of_Mental_Disorders#cite_note-93<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Mental Status Examination. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Mental_status_examination\">https:\/\/en.wikipedia.org\/wiki\/Mental_status_examination<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Therapeutic Assessment. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Therapeutic_assessment\">https:\/\/en.wikipedia.org\/wiki\/Therapeutic_assessment<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Classification, Diagnosis and Assessment of Abnormal Behavior. <strong>Authored by<\/strong>: Sonja Ann Miller. <strong>Provided by<\/strong>: Hudson Valley Community College. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/courses.lumenlearning.com\/hvcc-abnormalpsychology\/chapter\/3-3-steps-in-the-diagnostic-process\/\">https:\/\/courses.lumenlearning.com\/hvcc-abnormalpsychology\/chapter\/3-3-steps-in-the-diagnostic-process\/<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><li>Community Mental Health Act. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Community_Mental_Health_Act\">https:\/\/en.wikipedia.org\/wiki\/Community_Mental_Health_Act<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Dimensional models of personality disorders. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Dimensional_models_of_personality_disorders#Clinical_diagnosis\">https:\/\/en.wikipedia.org\/wiki\/Dimensional_models_of_personality_disorders#Clinical_diagnosis<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Psychotherapy. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Psychotherapy\">https:\/\/en.wikipedia.org\/wiki\/Psychotherapy<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">All rights reserved content<\/div><ul class=\"citation-list\"><li>Case Conceptualization. <strong>Provided by<\/strong>: Psychotherapy Academy. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?v=NOKCHeEyS9E\">https:\/\/www.youtube.com\/watch?v=NOKCHeEyS9E<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-1286-1\">Halpern, L, Trachtman, H. and Duckworth, K. \"From Within: A Consumer Perspective on Psychiatric Hospitals,\" in Textbook of Hospital Psychiatry, S. Sharfstein, F. Dickerson and J. Oldham eds. American Psychiatric Publishing, 2009, pp. 237\u2013244. <a href=\"#return-footnote-1286-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-1286-2\">Deb, K. S., &amp; Balhara, Y. P. (2013). Dhat syndrome: a review of the world literature. Indian journal of psychological medicine, 35(4), 326\u2013331. https:\/\/doi.org\/10.4103\/0253-7176.122219 <a href=\"#return-footnote-1286-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-1286-3\"><span style=\"font-size: 1em;\">\u201cWhat Is Psychotherapy?\u201d <\/span><em style=\"font-size: 1em;\">American Psychological Association<\/em><span style=\"font-size: 1em;\">. <\/span><a style=\"font-size: 1em;\" href=\"https:\/\/www.apa.org\/ptsd-guideline\/patients-and-families\/psychotherapy\">https:\/\/www.apa.org\/ptsd-guideline\/patients-and-families\/psychotherapy<\/a> <a href=\"#return-footnote-1286-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-1286-4\">wikiHow. \u201cHow to Write a Mental Health Treatment Plan.\u201d Accessed December 9, 2020. https:\/\/www.wikihow.com\/Write-a-Mental-Health-Treatment-Plan. <a href=\"#return-footnote-1286-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":29,"menu_order":12,"template":"","meta":{"_candela_citation":"[{\"type\":\"cc\",\"description\":\"DSM\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Diagnostic_and_Statistical_Manual_of_Mental_Disorders#cite_note-93\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Mental Status Examination\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Mental_status_examination\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Therapeutic Assessment\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Therapeutic_assessment\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Classification, Diagnosis and Assessment of 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