Presenting Concern
Specifies how all parties involved are defining the problem: client, family, friends, school, work, legal system, society, and so on.
Background Information
Summarizes recent changes, including precipitating events as well as related historical background.
Strengths and Diversity
Identifies personal, relational, and spiritual strengths as well as resources and limitations related to diversity issues.
Clinical Assessment
Assessment of psychiatric and related symptoms.
Cultural Formulation
Conceptualizing how diversity factors impact conceptualization, clinical assessment and intervention.
Recovery Model
Uses a social model of disability; de-emphasizes diagnostic labeling and emphasizes psychosocial functioning.
10 Principles of Mental Health Recovery Model
- Self-direction
- Individualized/person-centered
- Empowerment
- Holistic
- Nonlinear
- Strengths-based
- Peer support
- Respect
- Responsibility
- Hope
Parity Diagnoses
Diagnoses that are reimbursed at the same level of physical health disorders.
International Statistical Classification of Diseases and Related Health Problems
(ICD)
Most widely used set of diagnostic codes, and like the DSM, attempts to statistically classify health disorders.
Dimensional Approach
Variation of intensity on a given symptom or dimension: mild, moderate, severe.
Mental Status Exam
Used to gather psychological information necessary to make a diagnosis.
Cross-cutting Symptoms
Those symptoms that are seen across diagnoses; these are broad and general areas of functioning such as mood, anxiety, and insomnia.
Introduced in the DSM-5
Level 1 Cross-Cutting Measure
A measure created with the DSM-5 to help assess clients at the beginning of treatment to determine if further assessment is needed in a given area.
Cultural Identity of the Individual
Involves identifying important racial, ethnic, and cultural reference groups as well as other clinically relevant aspects of identity such as religious affiliation, socioeconomic status, sexual orientation, and migrant status.
Cultural Conceptualization of Distress
Requires outlining the cultural constructs and significance of presenting symptoms.
Contextual Factors
Factors such as age, ethnicity, family dynamics, language, religion, economic issues, sexual orientation, trauma history, addictions, cognitive ability, and how these might affect the diagnosis process.
Medical Considerations
Diagnoses with symptoms that typically warrant referral including depression, anxiety, mania, psychosis, trauma, disordered eating, alcohol/substance abuse, sleep disorders, etc.
Medical Necessity
Defined as a significant impairment in functioning, a high probability of significant impairment, and/or probable developmental arrest in children.
Usually required for third-party reimbursement
Sexual Abuse
Inappropriate sexual contact with a minor by adult or another minor; may or may not be consensual (defined by state laws).
Physical Abuse
Hitting, beating, kicking, or otherwise inflicting bodily harm by hand, with an object, and/or other means (e.g., locking child in enclosed space); includes most forms of spanking.
Emotional Abuse
Inflicting severe psychological harm such as fear of death, physical intimidation, intense rejection and disapproval, etc.
Neglect
Failing to provide for basic physical needs of child such as sufficient food, clothing, shelter, health needs, etc.
Safety Plans
Developed for any situation in which potential risk is identified such as passive suicidal ideation, history of cutting, history of abuse, etc.
Commitment to Treatment
An agreement between the client and counselor in which the client agrees to commit to the treatment process.
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DSM-5-TR Diagnosis104
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Mental Status and Clinical Assessment52
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Law, Ethics, and Crisis47
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General Treatment, Tx Planning, and Termination32
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Systemic and Cybernetic Foundations38
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Strategic and Systemic Theories35
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Structural Family Therapy35
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Intergenerational/Bowen Therapy31
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Experiential-Satir Family Therapy22
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Emotionally Focused Couple and Family Therapy22
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CBT/CBFT41
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Rational Emotive Behavioral Therapy25
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Dialetic Behavior Therapy (DBT)19
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Psychodynamic Family Therapy22
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Attachment-Based Psychotherapy (Psychodynamic)28
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Object Relations Therapy26
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Self Psychology20
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Postmodern: Narrative & Solution-Focused41
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Person-Centered Therapy (Carl Rogers)21
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Gestalt Therapy (Fritz Perls)19
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Family Development Theories35
