Clinician's Thesaurus: The Guide to Conducting Interviews and Writing Psychogical Reports

Description

Cover Half Title Page Title Page Copyright About the Author Contents Acknowledgments and an Invitation Getting Oriented to the Clinician’s Thesaurus What Is the Clinician’s Thesaurus and What Does It Do? How This Book Is Organized Internet Resources in the Clinician’s Thesaurus Understanding the Style and Format of the Chapters Example of a Report Constructed with the Clinician’s Thesaurus Some Ways to Use the Clinician’s Thesaurus A Cautionary Note and Disclaimer A Functional Guide to Report Construction The Nature of Reports, the Steps of Their Construction, and the Corresponding Portions of the Clinician’s Thesaurus Sample Report Using the Clinician’s Thesaurus Further Guidelines and Advice on Report Writing Part I. Conducting a Mental Health Evaluation 1. Beginning and Ending the Interview 1.1. Structuring the Interview 1.2. Introducing Yourself and Noting Possible Communication Difficulties 1.3. Assessing the Client’s Understanding of the Interview Situation 1.4. Obtaining Informed Consent 1.5. Other Points for All Interviews 1.6. Eliciting the Chief Concern/Complaint/Issue 1.7. Eliciting the Client’s Understanding of the Problem 1.8. Dimensionalizing the Concern/Problem 1.9. Ending the Interview 1.10. Collections of Tools for Screening and Monitoring 2. Mental Status Evaluation Questions/Tasks 2.1. Introduction to the Mental Status Questions 2.2. Background Information Related to Mental Status 2.3. Rancho Los Amigos Cognitive Scale 2.4. Screening Tests for Cognitive Impairment 2.5. Orientation 2.6. Attention 2.7. Concentration 2.8. Comprehension of Language 2.9. Eye–Hand Coordination/Perceptual–Motor Integration/Dyspraxia/Constructional Ability 2.10. Memory 2.11. Fund of Information 2.12. Opposites 2.13. Differences 2.14. Similarities/Analogies 2.15. Absurdities 2.16. Calculation Abilities 2.17. Abstract Reasoning/Proverbs 2.18. Paired Proverbs 2.19. Practical Reasoning 2.20. Social Judgment 2.21. Decision Making 2.22. Self-Image 2.23. Insight into Disorder 2.24. Strengths and Coping 2.25. Mental Status Evaluation Checklist 3. Questions about Signs, Symptoms, and Other Behavior Patterns 3.1. Introduction to the Questions about Signs, Symptoms, and Behavior Patterns 3.2. Abuse (Nonsexual)/Neglect of an Adult (Partner or Elder) 3.3. Abuse (Sexual) of an Adult 3.4. Affect/Mood 3.5. Anxiety 3.6. Body Dysmorphic Disorder 3.7. Compliance–Noncompliance with Treatment 3.8. Compulsions 3.9. Delusions 3.10. Depression 3.11. Dissociative Experiences 3.12. Eating Disorders 3.13. Gay, Lesbian, and Bisexual Identity Inquiry 3.14. Gender Identity 3.15. Gender Identity: Transgender and Gender-Nonconforming 3.16. Hallucinations 3.17. Illusions 3.18. Impulse Control 3.19. Mania 3.20. Obsessions 3.21. Organicity/Cognitive Disorders 3.22. Pain, Chronic 3.23. Paranoia 3.24. Phobias 3.25. Self-Injury 3.26. Sexual History 3.27. Sleep 3.28. Substance Abuse: Drugs and Alcohol 3.29. Substance Use: Tobacco and Caffeine 3.30. Suicide and Self-Destructive Behavior 3.31. Violence Part II. Standard Terms and Statements for Wording Psychological Reports A. Introducing the Report 4. Beginning the Report: Preliminary Information 4.1. Heading and Dates for the Report 4.2. Sources of Information for the Report 4.3. Identifying Information about the Client 4.4. Self-Sufficiency in Appearing for Examination 4.5. Consent Statements 4.6. Reliability/Validity Statements 4.7. Confidentiality Notices 4.8. Ethical Considerations in Report Writing 5. Referral Reasons 5.1. Statement of Referral Reason 6. Background Information and History 6.1. History/Course of the Present Problem/Illness/Chief Complaint/Concern 6.2. Medical History and Other Findings 6.3. Personal, Family, and Social Histories, and Current Social Situation 6.4. Adjustment 6.5. Social History for a Disability Examination 6.6. Family Genogram/Family Tree/Pedigree B. The Person in the Evaluation 7. Behavioral Observations 7.1. Appearance 7.2. Clothing/Attire 7.3. Movement/Activity 7.4. Speech Behavior 7.5. Other Behavioral Observations 8. Responses to Aspects of the Examination 8.1. Reaction to the Context of the Evaluation 8.2. Attention/Concentration/Effort 8.3. Response to the Methods of Evaluation/Tests/Questions 8.4. Persistence/Motivation 8.5. Relationship with the Examiner 8.6. Response to Success/Failure/Feedback 9. Presentation of Self 9.1. Dependency–Surgency 9.2. Presence/Style 9.3. Self-Image/Self-Esteem 9.4. Social Sophistication/Manners 9.5. Warmth–Coldness 9.6. Other Aspects of Self-Presentation 10. Emotional/Affective Symptoms and Disorders 10.1. General Aspects of Mood and Affects 10.2. Anger 10.3. Anxiety/Fear 10.4. Bipolar I Disorder 10.5. Bipolar II Disorder 10.6. Cyclothymia 10.7. Depression 10.8. Guilt/Shame 10.9. Mania 10.10. Panic 10.11. Seasonal Affective Disorder 10.12. Sexual Interest 10.13. Other Affects/Emotional Reactions 11. Cognition and Mental Status 11.1. No Pathological Findings: Summary Statements 11.2. Arithmetic 11.3. Attention 11.4. Concentration/Task Persistence 11.5. Consciousness Levels 11.6. Decision Making 11.7. Dementia 11.8. Executive Functions 11.9. Information 11.10. Insight 11.11. Intelligence and Cognition: Assessment 11.12. Intelligence Scores: Classifications 11.13. Memory 11.14. Moral/Social Judgment and Knowledge 11.15. Orientation 11.16. Reality Testing 11.17. Reasoning/Abstract Thinking/Concept Formation 11.18. Social Maturity 11.19. Stream of Thought 11.20. Test Judgment: Summary Statements 11.21. Other Summary Statements for Cognitive Components of Mental Status 12. Abnormal Signs, Symptoms, and Syndromes 12.1. Abuse 12.2. AIDS Dementia Complex 12.3. Attention-Deficit/Hyperactivity Disorder 12.4. Autism Spectrum Disorders 12.5. Body Dysmorphic Disorder 12.6. Chronic Fatigue Syndrome/Myalgic Encephalomyelitis 12.7. Compulsions 12.8. Delusions 12.9. Denial 12.10. Depersonalization and Derealization 12.11. Dual Diagnoses 12.12. Eating Disorders 12.13. Fetal Alcohol Syndrome 12.14. Gambling 12.15. Hallucinations 12.16. Hoarding 12.17. Hypochondriasis 12.18. Illusions 12.19. Impulse-Control Disorders 12.20. Intimate Partner Violence/Domestic Violence 12.21. Malingering 12.22. Obsessions 12.23. Pain Disorder/Chronic Pain Syndrome 12.24. Paranoia 12.25. Phobias 12.26. Postconcussive Syndrome 12.27. Posttraumatic Stress Disorder 12.28. Premenstrual Dysphoric Disorder 12.29. Rape Trauma Syndrome 12.30. Schizophrenia 12.31. Self-Injurious Behavior 12.32. Sexual Impulsivity/Addiction/Compulsion, Hypersexuality 12.33. Side Effects of Psychotropic Medications/Adverse Drug Reactions 12.34. Sleep Disturbances 12.35. Stalking 12.36. Substance Use, Abuse, and Dependence 12.37. Suicide 12.38. Trafficking in Persons 12.39. Violent Behaviors 13. Personality Patterns 13.1. Models of Personality Diagnosis 13.2. Adult Children of Alcoholic/Addicted Parents 13.3. Antisocial Personality 13.4. Authoritarian Personality 13.5. Avoidant Personality 13.6. Borderline Personality 13.7. Codependent Personality 13.8. Compulsive Personality 13.9. Dependent Personality 13.10. Dissociative Identity Disorder 13.11. Histrionic Personality 13.12. Narcissistic Personality 13.13. Normal/Healthy Personality 13.14. Obsessive Personality 13.15. Paranoid Personality 13.16. Passive–Aggressive Personality 13.17. Sadistic Personality 13.18. Schizoid Personality 13.19. Schizotypal Personality 13.20. Self-Defeating Personality C. The Person in the Environment 14. Activities of Daily Living 14.1. Assessment 14.2. Assistance Level Required/Degree of Independence 14.3. Child Care 14.4. Chores/House Care/Domestic Skills 14.5. Cooking 14.6. Financial Skills 14.7. Hazard Recognition and Coping 14.8. Living Situation/Level of Support Needed 14.9. Quality of Performance 14.10. Self-Care Skills 14.11. Shopping 14.12. Transportation 14.13. Caregiver Burden 14.14. Summary Statements 15. Social/Community Functioning 15.1. General Lifestyle 15.2. Involvement in Social/Community Activities 15.3. Problems/Conflicts in Community Relating 16. Couple and Family Relationships 16.1. Systemic Family Constructs 16.2. Assessment of Families at Intake 16.3. Family Interviewing Method 16.4. Child Rearing/Raising: Aspects 16.5. Couple Relationships: Aspects 17. Vocational/Academic Skills 17.1. Basic Work Skills 17.2. History of Work 17.3. Language Skills: Reading and Writing Ability 17.4. Math Ability 17.5. Special Considerations for Disability Reports 17.6. Vocational Competence/Recommendations 18. Recreational Functioning 18.1. Entertainment: TV/Radio/Online Programming/Music 18.2. Hobbies 18.3. Sports 18.4. Reading Materials 18.5. Participation/Performance Quality 19. Other Specialized Evaluations 19.1. Bariatric Surgery 19.2. Coping Ability/Stress Tolerance 19.3. Culturally Sensitive Formulations 19.4. Financial Competence/Competence to Manage Funds 19.5. The Refugee Experience 19.6. Religious and Spiritual Concerns D. Completing the Report 20. Summary of Findings and Conclusions 20.1. Overview 20.2. Beginning the Summary 20.3. Summary of Previous Information 20.4. Relevant Findings and/or Conclusions 20.5. Diagnostic Statement 20.6. Consultations and Further Evaluations 20.7. Summarizing Treatment 21. Diagnostic Statement/Impression 21.1. ICD and DSM 21.2. Introduction to the Reference List of Psychiatric Diagnoses 21.3. Qualifiers for Diagnosis 21.4. The Reference List of Psychiatric Diagnoses from ICD-10-CM 22. Recommendations 22.1. Need for Treatment/Medical Necessity of Treatment 22.2. Offering Effective Treatments 22.3. Treatment Options/Case Disposition 22.4. Types of Therapies/Services 23. Prognostic Statements 23.1. General Prognostic Statement 23.2. Other Statements 24. Closing Statements 24.1. Value of the Information 24.2. Thanking the Referrer 24.3. Continued Availability 24.4. Signature, Etc. 24.5. Disclaimer Part III. Useful Resources 25. Treatment Planning and Treatment Plan Formats 25.1. The Flow and Nature of Treatment Planning 25.2. Some Advice on Writing Treatment Plans 25.3. Various Formats for Treatment Plans 25.4. A Treatment Plan Format for Case Conceptualization 25.5. Treatment Plan Components for Clients with Substance Abuse 25.6. Treatment Plan Components for Crisis Interventions 25.7. The Recovery Paradigm and Its Language 25.8. Checklist of Strengths 25.9. Outcome Measures/Goal Achievements 26. Formats for Reports, Evaluations, and Summaries 26.1. A Standard Format for Reports of Evaluations 26.2. Format for Psychodynamic Evaluations: Developmental Model 26.3. The Psychodynamic Diagnostic Manual–2 Format 26.4. Themes for Evaluations from an Existential Perspective 26.5. Formats for Therapy Notes 27. Listing of Common Psychiatric and Psychoactive Drugs 27.1. Lists of Medications by Trade and Generic Names 27.2. Street Drugs’ Names 27.3. Results of Medication Treatment: Descriptors 27.4. Drug Resources for the Clinician 28. Psychiatric Masquerade of Medical Conditions 28.1. Introduction 28.2. Anxiety 28.3. Sexual Dysfunction 28.4. Depression 28.5. Mania 28.6. Organic Brain Syndrome/Dementia 28.7. Psychosis 28.8. Medication-Induced Psychiatric Conditions Appendices A. Abbreviations in Common Use A.1. Clinicians/Mental Health Professionals A.2. Treatment A.3. Diagnoses and Conditions A.4. Relations A.5. General Aids to Recording A.6. Legal Terms A.7. Medication Regimens B. Annotated Readings in Assessment, Interviewing, and Report Writing Assessment Interviewing Report Writing and Person-First Language Feedback Solicitation Form References Index