Assessment In Counseling Procedures And Practices Pdf


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Formal vs. Informal Assessments

NCBI Bookshelf. Center for Substance Abuse Treatment. This chapter consists of three parts: 1 an overview of the basic screening and assessment approach that should be a part of any program for clients with co-occurring disorders COD ; 2 an outline of the 12 steps to an ideal assessment, including some instruments that can be used in assessing COD; and 3 a discussion of key considerations in treatment matching.

Ideally, information needs to be collected continuously, and assessments revised and monitored as the client moves through recovery. A comprehensive assessment as described in the main section of this chapter leads to improved treatment planning, and it is the intent of this chapter to provide a model of optimal process of evaluation for clients with COD and to encourage the field to move toward this ideal.

Nonetheless, the panel recognizes that not all agencies and providers have the resources to conduct immediate and thorough screenings. Therefore, the chapter provides a description of the initial screening and the basic or minimal assessment of COD necessary for the initial treatment planning.

A basic assessment covers the key information required for treatment matching and treatment planning. Specifically, the basic assessment offers a structure with which to obtain.

Note that medical issues including physical disability and sexually transmitted diseases , cultural issues, gender-specific and sexual orientation issues, and legal issues always must be addressed, whether basic or more comprehensive assessment is performed.

The consensus panel assumes that appropriate procedures are in place to address these and other important issues that must be included in treatment planning. However, the focus of this chapter, in keeping with the purpose of this TIP, is on screening and assessment related to COD.

This section provides an overview of the screening and assessment process for COD. In carrying out these processes, counselors should understand the limitations of their licensure or certification authority to diagnose or assess mental disorders.

Generally, however, collecting assessment information is a legitimate and legal activity even for unlicensed providers, provided that they do not use diagnostic labels as conclusions or opinions about the client. Information gathered in this way is needed to ensure the client is placed in the most appropriate treatment setting as discussed later in this chapter and to assist in providing mental disorder care that addresses each disorder.

In addition, there are a number of circumstances that can affect validity and test responses that may not be obvious to the beginning counselor, such as the manner in which instructions are given to the client, the setting where the screening or assessment takes place, privacy or the lack thereof , and trust and rapport between the client and counselor.

Throughout the process it is important to be sensitive to cultural context and to the different presentations of both substance use and mental disorders that may occur in various cultures. View in own window.

Screening is a formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular disorder and, in this context, the possibility of a co-occurring substance use or mental disorder.

Note that the screening process does not necessarily identify what kind of problem the person might have or how serious it might be, but determines whether or not further assessment is warranted. A screening process can be designed so that it can be conducted by counselors using their basic counseling skills. There are seldom any legal or professional restraints on who can be trained to conduct a screening. Screening processes always should define a protocol for determining which clients screen positive and for ensuring that those clients receive a thorough assessment.

Additionally, the screening protocol details exactly what takes place after a client scores in the positive range and provides the necessary standard forms to be used to document both the results of all later assessments and that each staff member has carried out his or her responsibilities in the process.

So, what can a substance abuse treatment counselor do in terms of screening? All counselors can be trained to screen for COD. In substance abuse treatment or mental health service settings, every counselor or clinician who conducts intake or assessment should be able to screen for the most common COD and know how to implement the protocol for obtaining COD assessment information and recommendations.

This instrument is intended for use as a rough screening device for clients seeking admission to substance abuse treatment programs. Note that while the consensus panel believes that this instrument is useful, it has received limited validation [ Carroll and McGinley ]. While both screening and assessment are ways of gathering information about the client in order to better treat him, assessment differs from screening in the following way:. A basic assessment consists of gathering key information and engaging in a process with the client that enables the counselor to understand the client's readiness for change, problem areas, COD diagnosis es , disabilities, and strengths.

An assessment typically involves a clinical examination of the functioning and well-being of the client and includes a number of tests and written and oral exercises. The COD diagnosis is established by referral to a psychiatrist, clinical psychologist, or other qualified healthcare professional. Assessment of the client with COD is an ongoing process that should be repeated over time to capture the changing nature of the client's status.

Intake information consists of. It is essential for treatment planning that the counselor organize the collected information in a way that helps identify established mental disorder diagnoses and current treatment. The text box below highlights the role of instruments in the assessment process. Understanding a client's mental health symptoms and impairments that persist during periods of abstinence of 30 days or more can be useful, particularly in understanding what the client copes with even when the acute effects of substance use are not present.

On the other hand, if mental health symptoms even suicidality or hallucinations resolve in less than 30 days with abstinence from substances, then these symptoms are most likely substance induced and the best treatment is maintaining abstinence from substances. What—in detail—has happened in the past? Clinician and client together should try to understand the specific effects that substances have had on that individual's mental health symptoms, including the possible triggering of psychiatric symptoms by substance use.

Clinicians also should attempt to document the diagnosis of a mental disorder, when it has been established, and determine diagnosis through referral when it has not been established.

The consensus panel notes that many, if not most, individuals with COD have well-established diagnoses when they enter substance abuse treatment and encourages counselors to find out about any known diagnoses. A comprehensive assessment serves as the basis for an individualized treatment plan. Appropriate treatment plans and treatment interventions can be quite complex, depending on what might be discovered in each domain.

This leads to another fundamental principle:. The following three cases illustrate how the above factors help to generate an integrated treatment plan that is appropriate to the needs and situation of a particular client. Maria M. She is not in an intimate relationship at present and there is no current indication that she is at risk for either violence or self-harm. She also has persistent major depression and panic treated with antidepressants. She is very motivated to receive treatment.

Individual, group, and family interventions could be coordinated by the primary counselor from opioid maintenance treatment. The focus of these interventions might be on relapse prevention skills, taking medication as prescribed, and identifying and managing trauma-related symptoms without using. An appropriate long-term goal would be to establish abstinence and engage Maria in longer-term psychotherapeutic interventions to reduce trauma symptoms and help resolve trauma issues.

On the other hand, if a local mental health center had a psychiatrist trained and licensed to provide Suboxone the combination of buprenorphine and nalaxone , her case could be based in the mental health center. The client is a year-old married, employed African-American man with cocaine dependence, alcohol abuse, and bipolar disorder stabilized on lithium who is mandated to cocaine treatment by his employer due to a failed drug test.

George T. He complains that his mood swings intensify when he is using cocaine. The client is a year-old single Caucasian female with a diagnosis of paranoid schizophrenia, alcohol dependence, crack cocaine dependence, and a history of multiple episodes of sexual victimization. Jane B. She has made frequent visits to the local emergency room for both mental health and medical complaints, but refuses any followup treatment.

Her main requests are for money and food, not treatment. Jane has been offered involvement in a housing program that does not require treatment engagement or sobriety but has refused due to paranoia regarding working with staff to help her in this setting. All of these cases are appropriate examples of integrated treatment. The purpose of the assessment process is to develop a method for gathering information in an organized manner that allows the clinician to develop an appropriate treatment plan or recommendation.

The remainder of this chapter will discuss how this assessment process might occur, and how the information gathered leads to a rational process of treatment planning. In Step 12 of the assessment process, readers will find an expanded treatment plan for the three clients discussed above.

This chapter is organized around 12 specific steps in the assessment process. Through these steps, the counselor seeks to accomplish the following aims:.

Note that although the steps appear sequential, in fact some of them could occur simultaneously or in a different order, depending on the situation. It is particularly important to identify and attend to any acute safety needs, which often have to be addressed before a more comprehensive assessment process can occur.

Sometimes, however, components of the assessment process are essential to address the client's specific safety needs. For example, if a person is homeless, more information on that person's mental status, resources, and overall situation is required to address that priority appropriately.

Finally, it must be recognized that while the assessment seeks to identify individual needs and vulnerabilities as quickly as possible to initiate appropriate treatment, assessment is an ongoing process: As treatment proceeds and as other changes occur in the client's life and mental status, counselors must actively seek current information rather than proceed on assumptions that might be no longer valid.

In the following discussion, validated assessment tools that are available to assist in this process are discussed with regard to their utility for counselors. There are a number of tools that are required by various States for use in their addiction systems e. Particular attention will be given to the role of these tools in the COD assessment process, suggesting strategies to reduce duplication of effort where possible. Basic information about each instrument is given in appendix G , and readers can obtain more detailed information regarding administration and interpretation from the sources given for obtaining these instruments.

As a final point, this discussion primarily is directed toward substance abuse treatment clinicians working in substance abuse treatment settings, though many of the steps apply equally well to mental health clinicians in mental health settings.

At certain key points in the discussion, particular information relevant to mental health clinicians is identified and described. The first step in the assessment process is to engage the client in an empathic, welcoming manner and build a rapport to facilitate open disclosure of information regarding mental health problems, substance use disorders, and related issues. The aim is to create a safe and nonjudgmental environment in which sensitive personal issues may be discussed.

Counselors should recognize that cultural issues, including the use of the client's preferred language, play a role in creating a sense of safety and promote accurate understanding of the client's situation and options. Such issues therefore must be addressed sensitively at the outset and throughout the assessment process. All staff, as well as substance abuse treatment and mental health clinicians, in any service setting need to develop competency in engaging and welcoming individuals with COD.

It is also important to note that while engagement is presented here as the first necessary step for assessment to take place, in a larger sense engagement represents an ongoing concern of the counselor—to understand the client's experience and to keep him or her positive and engaged relative to the prospect of better health and recovery. Substance abuse and mental health counselors are encouraged to identify individuals with COD, welcome them into the service system, and initiate proactive efforts to help them access appropriate treatment in the system, regardless of their initial site of presentation.

The recommended attitude is as follows: The purpose of this assessment is not just to determine whether the client fits in my program, but to help the client figure out where he or she fits in the system of care, and to help him or her get there. In the past, the attitude was that the client with COD was the exception. Today, clinicians should be prepared to demonstrate responsiveness to the requirements clients with COD present.

Counselors should be careful not to label mental health symptoms immediately as caused by addiction, but instead should be comfortable with the strong possibility that a mental-health condition may be present independently and encourage disclosure of information that will help clarify the meaning of any COD for that client.

Person-centered assessment emphasizes that the focus of initial contact is not on filling out a form or answering several questions or on establishing program fit, but rather on finding out what the client wants, in terms of his or her perception of the problem, what he or she wants to change, and how he or she thinks that change will occur. Mee-Lee has developed a useful guide that illustrates the types of questions that might be asked in a person-centered assessment in an addiction setting see Figure It should be noted, however, that this is not a validated tool.

While each step in this decision tree leads to the next, the final step can lead back to a previous step, depending on the client's progress in treatment. Source : Adapted from Mee-Lee Answers to some of these important questions inevitably will change over time. As the answers change, adjustments in treatment strategies may be appropriate to help the client continue to engage in the treatment process.

Assessment in Counseling: A Guide to the Use of Psychological Assessment Procedures

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Assessment Procedures for Counselors and Helping Professionals, 9th Edition

NCBI Bookshelf. Why screen universally for trauma in behavioral health services? Exposure to trauma is common; in many surveys, more than half of respondents report a history of trauma, and the rates are even higher among clients with mental or substance use disorders. Unrecognized, unaddressed trauma symptoms can lead to poor engagement in treatment, premature termination, greater risk for relapse of psychological symptoms or substance use, and worse outcomes. Screening can also prevent misdiagnosis and inappropriate treatment planning.

Assessment in Counseling: Procedures and Practices

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Title: Assessment in counseling: Procedures and practices / Danica G. Hays. Description: Diagnostic and Statistical Manual of Mental Disorders.

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