Treatment Plan, Theoretical Intervention, and Documentation

Intake, Clinical Assessment and Ethical documentation

Introduction

The first contact between a counselor and client is through the intake interview. This is an assessment by which information is gathered to identify the problem, determine a diagnosis, set goals, formulate the case, and determine a treatment plan (Sommers-Flanagan & Sommers-Flanagan, 2017). It is unwise to initiate counseling sessions without an intake interview. Without an intake interview, the counselor is not able to meet the objectives of the intake session. Sommers-Flanagan and Sommers-Flanagan describes the intake interview as having five stages, 1) introduction, 2) opening, 3) body, 4) closing, and 5) termination (2017). In the Intake interviews counselors should consider sex, age, gender, race, and any medical conditions of the client.

The case study presented in the following pages is of fifty-one-year-old Katia. Katia is biracial with an African American mother and a Caucasian father. She was raised in a home where both Catholicism and Southern Baptist beliefs were exercised in the home, where she lived with her passive mother, father, and sister. Katia’s dad would hit them, but she thought it was just part of the discipline process as he loved on them so much so, she felt it could be nothing other than discipline. Katia and her sister had to be perfect with grades and behavior. She describes her home environment as one of uncertainty but peaceful at times – never knowing what to expect. Although Katia was bullied as a teenager, her dad would not allow her to see a therapist even though Katia wanted to. Additionally, during her teenage years, Katia had thoughts of committing suicide with her dad’s gun and stopped attending church services before leaving for college. She felt as though she was being fake about her spirituality and preferred not to be that way. Katia received her bachelor’s degree and when on to marry husband of twenty-five years with whom she shares a twenty-three-year-old daughter. Both she and her husband are educators and have not issues financially. Katia has three best friends from college she is in contact with daily. She has no regrets of not having friendships from high school and had only one other boyfriend who broke her heart. Katia has not had any medical issues other than a hysterectomy that forced her into early menopause at the age of forty-three. This paper will summarize the skills, explore all ethical, legal, and cultural considerations of said case and identify the assessment best utilize with Katia.

Identification of Case Summarization of Skills

Katia sought counseling after having difficulty making decisions, feeling unsettled and uneasy, inability to sleep, having points of anxiety and panic when thinking about the future, struggles with her identity, sleeplessness, feeling developmentally stuck, lack of communication with father and other adults and realizing she is not over her mother’s death. As Katia is greeted to begin the session, she is engaged with small talk and asked how the traffic on her way to the office was and the correct pronunciation of her name. Katia is informed of the counselor’s role and what can be expected during the session. She is also asked if she has any questions about the process. Katia and the counselor discuss the importance of confidentiality and the limits of that confidentiality. Katia understands that threats to harm herself or someone else and discovery of child or elder abuse will void her privacy. The therapeutic method used in the session with Katia is Psychoanalysis. This approach provides a complex analysis of human behavior because it describes a situation in which human beings are motivated by unconscious wishes and desires, are largely unaware of these unconscious motivations, and are resistant to being made aware of them  (Redekop, Luke, & Malone, 2017). The room setting is neat, clean, and organized. Lighting is soft and chairs are situated in a face to face arrangement with a coffee table between us.  A white noise machine is placed outside the door for added privacy.  Katia is informed that notes will be taken to assist with remembering key important facts.

Once the introduction is complete, the session moves toward the opening. This signals to Katia that the session will move toward more direct questioning or conversation. The opening is where more information is gained as to the purpose for coming into counseling. If Katia struggles responding to the opening question of her purpose for coming in, the counselor should express empathy, understanding and flexibility to get her to open up. As clients begin talking, ideally, counselors will observe the responses and modify the approach accordingly. With clients who are very verbal, you may need to interject yourself into the interview early and often.

In the body of the intake interview, the client is assessed by the counselor. Making some physical, visual, auditory judgements. The judgements will answer questions like, is Katia likeable, hostile, self-absorbed, internalizing or externalizing? Is Katia timid? What type of interpersonal and coping skills does Katia have? Is Katia showing signs of distress (Sommers-Flanagan & Sommers-Flanagan, 2017)?  The counselor can determine the mental disorder based on what is observed during the clinical interview based on normal/healthy functioning compared to disturbed functioning. During the body of the interview, therapists can use interventions to facilitate client change. Ideally, most interventions will be applied after a suitable assessment has been completed. However, in many cases, assessment and intervention happen simultaneously.

The closing phase of the interview is an opportunity to revisit some points made in introduction phase, like the counselor’s role and summarize the issues discussed. Additionally, the counselor should reassure Katia of the great job she did expressing herself during their first meeting and inform her that the decision to seek counseling is great step in the right direction. Instill hope that the counseling will help her deal with the issues she presents. This also a good time to discuss committing to future sessions and provide an initial case formulation. decision.

Termination is the last phase of the interview. Counselors should casually monitor the time and operate within the fifty-minute time boundary.  Counselors will guide and control the termination.

Exploration of Ethical, Legal, and Cultural Considerations

The ACA Code of Ethics plays a vital role in the administration and deliverance of a counseling services. The codes govern the ethical, legal, and cultural considerations of the counseling relationship and services. The following codes align with the Introduction phase, Section A, codes A.1, Client Welfare, counselor will respect the dignity of the client,  A.1.b. Records documentation, counselor will safeguard and maintain documentation, A.2.a., Informed consent, client gives consent for treatment, A.2.b., Type of Information Needed, inform client of procedures, limitations, goals, techniques, etc., A.2.c., Developmental and Cultural Sensitivity, communicate information in ways that are culturally and developmentally appropriate, A.2.e., Mandated Clients, consider this code if the client is referred to counseling from a third party, and A.4.a. Avoiding Harm, counselors work to avoid harming the client. Section B addresses Confidentially and Privacy and is discussed in the Introduction as well. Code B.1.a., Multicultural and Diversity Considerations, counselors will consider how clients of different cultures view confidentially and also have multicultural self-awareness, B.1.b., Respect for Privacy, only request information only when it is beneficial to the counseling process. Section C is considered in both Introduction and Opening. The ACA Code C.2.a., Boundaries of Competence, the counselor will only practice within the boundaries of his or her competence based on education and training (ACA Code of Ethics, 2020).

During counseling and the intake interview sessions, the counselor may receive medical information regarding the client. This information falls within the Health Insurance Portability and Accountability Act and is protected. Counselors should always strive to make the client feel as comfortable as possible. Letting the clients know that medical information is protected by the ACA Codes and HIPPA Laws will give the client an added sense of security.

Mental Health Counselors should make every effort to learn more about other cultures. Understanding the biases that lie within and work to keep those biases at bay. The 2014 ACA Code of Ethics A.4.b. discussing personal values and state counselors should avoid imposing their own values, beliefs, behaviors, and attitudes during counseling sessions.

Assessment Identification

Given Katia’s suicidal ideations in the past, she is given a comprehensive suicide assessment. A RIP SCIP will gather more information about Katia’s thoughts, plans, agitations, self-control, suicide intent and reasons to live (Sommers-Flanagan & Sommers-Flanagan, 2017). The Cultural Assessment for Risk of Suicide (CARS) is another assessment that help understand Katia’s past suicide ideations and discover if there are any current ideations. It is a 39-point scale and extremely useful in the African American community and can enhance the client’s cultural sensitivity. The Suicide Ideation Scale would help determine if there are any current or more recent thoughts of suicide. It is a ten item self-report scale that measures suicidal thoughts (Sommers-Flanagan & Sommers-Flanagan, 2017).

Exploration of Interview Tasks

The counselor will want to begin building a positive therapeutic relationship with Katia immediately, starting in the greeting. The approach to Katia assessment is non-judgmental and helpful. The counselor should allow Katia to speak freely and listen while acknowledging and paraphrasing what he or she is hearing. Counselors’ body language should be one that displays attentiveness and positivity. Counselor’s should stay away from negative behaviors likes head nods, “uh-huhs” and repeating the last word of the Katia’s statement (Sommers-Flanagan & Sommers-Flanagan, 2017). Katia mentioned being developmentally stuck – the counselor should encourage Katia by using therapeutic questions that will stimulate change. Questions such as, what do you want? Is it working? Should you make a new plan?, will help Katia identify goals, engage in self-evaluation, and develop plans for goal attainment.

Conclusion

This paper detailed the case study of 51-year-old Katia. The writer defined the role of the intake interview and its components, importance of establishing a positive therapeutic relationship with the Katia, and what assessments are pertinent to Katia’s case and establishing a treatment plan. The paper highlights the many factors affecting the counseling relationship and the behaviors and skills that will ensure a successful partnership. The writer drew a parallel to counseling skills and tasks and the ACA Code of Ethics. The writer stresses how both counseling techniques and the counseling relationship are important to the success of the therapy.