Reference no: EM133668758

Question

The process of screening first begins with obtaining informed consent to treat the client for services (GCU, 2024). Once consent is obtained, the client is screened to ensure that they are appropriate for services and level of care, if the client is not appropriate, referrals to appropriate services are made. After the screening process, a biopsychosocial is administered to gather demographics, determine the client's presenting problems, family and social history, medical and mental health history, current medications, legal history, vocational history, spiritual orientation, victim status, and previous treatment episodes. Next, a mental-status-exam is performed along with screening for suicidal/homicidal ideation and psychosis, protective factors, client strengths and positive supports (GCU, 2024). Next, to assess level of care an ASAM is performed, along with any other additional clinical assessments needed such as the Becks Scale for client's reporting depression (GCU, 2024).

When diagnosing, the DSM-5-TR and ICD-10 are used to determine any rule outs, provisional, and cross-cutting symptoms. Provisional diagnoses, that the therapist believes the client may meet full criteria for, are confirmed or ruled out, by gathering more information during the clinical interview and cross referencing with DSM criteria, before a final diagnosis is made (GCU, 2024). In situations with more than one diagnosis, a principal diagnosis is selected (GCU, 2024). During treatment planning, a master problem list is created whereby the client and counselor decide which to address first based upon the most critical presenting issues, Next, goals are established along with measurable objectives, interventions (or strategies), and expected completion dates (Young & Cashwell, 2017). Furthermore, informal assessments are conducted by the therapist weekly (inpatient) and monthly (outpatient) to monitor if goals are met. Moreover, treatment plan revisions are made as changes occur or as objectives/goals are met and new objectives/goals are created (GCU, 2024). As indicated by McCance-Katz (2019), a counselor may challenge a client's negative behaviors and thoughts by applying motivational interviewing via a collaborative partnership that expresses empathy rather than authority as they progress through the stages of change. Counselors should be supportive, ask open ended questions, affirm, use reflective listening, and summarize as they adhere to the four processes of engaging, focusing, evoking, and planning (McCance-Katz, 2019).