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A Systematic and Integrative Model For Mental Health Assessment and Treatment Planning
A Systematic and Integrative Model For Mental Health Assessment and Treatment Planning
A Systematic and
Integrative Model for
Mental Health Assessment
and Treatment Planning
Julie Gosselin
Mlanie Joanisse
Dedication
Mlanie Joanisse: I would like to dedicate this book to my clinical
supervisors of the University of Ottawa (especially Dr. Marlene Best and my
coauthor Dr. Gosselin), because their expertise and teachings influenced the
development of our integrative framework. I wish to also dedicate this to my
clinical students because their judicious questions and comments highlighted
the importance of developing a coherent framework and ultimately made me
a better clinician. At last, I would like to thank my husband, Norm, for his
unconditional support.
Julie Gosselin: I would like to dedicate this book to my clinical students who,
over the past decade, have taught me to refine my clinical thinking and to
better articulate my clinical training observations. I want to especially thank
my coauthor Dr. Mlanie Joanisse for agreeing to take on this challenge with
me: your intellectual rigor and clinical acumen are at the core of the creation
of this model. Finally, I would like to thank my husband and my family for
their unwavering support.
Abstract
This book sets the stage by providing a clear, systematic, and integrative
model for mental health assessment and treatment planning that can be
used in a variety of clinical settings, with a diverse adult clinical population. This book advocates for the importance of considering all aspects of
evidence-based practice (i.e., best available research, clinicians expertise,
and experience, as well as clients preferences and idiosyncrasies) when
conducting assessments and delivering psychological treatments. Special
attention is also given to the interdisciplinary aspects of delivering mental health care in todays fast-paced environments. If you are a seasoned
clinician or a beginner therapist, you will surely find this book useful
because it provides a general map that can be used regardless of your
specific theoretical orientations. The applied nature of the content makes
it easy and valuable for readers who wish to apply psychology integration
to their own practice. Specifically, case vignettes have been developed to
help readers gain a better understanding on how to apply the integrative
interprofessional framework into their practice. Finally, professors and supervisors will also find this book worthwhile as the authors incorporated
a chapter on the supervision and evaluation of assessment and treatment
planning competencies.
Keywords
assessment, evidence-based, integration, psychology, treatment
Contents
Acknowledgments....................................................................................xi
Chapter 1 A Transtheoretical Model for Psychotherapy
Integration1
Chapter 2 A Model of Assessment and Treatment Planning
Fit for the Modern Clinician19
Chapter 3 An Integrative Interprofessional Model for
Psychological Assessment31
Chapter 4 Conducting Psychological Assessment and Creating
aCase Formulation45
Chapter 5 An Integrative Interprofessional Model for
Psychological Treatment Planning and
Monitoring61
Chapter 6 Treatment Delivery and Monitoring85
Chapter 7 Conducting an Intake and Treatment
Planning Session95
Chapter 8 The Supervision and Evaluation of Assessment
and Treatment Planning Competency
Development113
Appendix A121
About the Authors137
Index..................................................................................................139
Acknowledgments
We would like to acknowledge Sheila N. Garland, PhD. Registered Clinical Psychologist and Assistant Professor of Psychology and Oncology at
Memorial University, St. Johns, Newfoundland for her judicious comments on the initial version of this book.
CHAPTER 1
See Norcross (2005) for a more in-depth discussion and presentation on these factors
in Nocross and Goldfried (2005)s Handbook of psychotherapy integration; a must
read for anyone wishing to better understand psychotherapy integration.
Misconceptions of EBP
Unfortunately, EBP has been sometimes misunderstood as the utilization
of manualized treatment protocols that have been empirically validated,
often using a randomized clinical trial (RCT). For some, the utilization
of the treatment manual is not conceived as one part of the treatment delivery as it should be, but it becomes the whole treatment. The clinicians
delivery of the treatment, the client idiosyncrasies, and the interaction
between these variables are not considered as important. This is problematic for various reasons, and the full discussion is outside of the scope of
this book,2 but we wish to address the main issues with this approach:
(1) clinicians often do not treat a homogeneous sample of patients with a
single diagnosis; (2) good therapy is inherently responsive to client needs
and preferences; and (3) RCTs cannot adequately address all issues related
to psychological health.
However, we are not against the use of validated treatment manuals or treatment based on diagnosis, nor do we reject RCTs; we believe
them to be laudable. In some instances, it can make pragmatic sense to
use a DSM-5 diagnosis to orient treatment plan given how the broader
health care system is organized. RCTs can also be pertinent in addressing some scientific endeavors and has greatly helped increase the legitimacy of psychological treatment in the health care system where
pharmaceutical approaches were often seen as the treatment of choice
(see Barlow, 2004 for a review). What we denounce is the systematic,
rigid use of these manuals and calling it evidence-based practice or
the use of DSM-5 disorders as analogous to a comprehensive case formulation. Instead, through our discussion of the three aforementioned
2
We encourage you to read Norcross, Beutler, and Levant (2006) for relevant and
interesting debates on EBP.
issues, we wish to make a case for a balanced approach and consideration of all components of EBP and are in favor of multiple sources of
evidence to inform practice.
Problem 1: Diagnosis as Case Formulation
In some graduate schools, it has been the norm to assess a person to
formulate a diagnosis and then plan treatment according to this diagnosis. The logic seems bulletproof and fairly congruent with our experience
when going to a physicians office. The doctor says I have X then Iwill
be prescribed Y. Yet, research has depicted a more complex picture when
applied to psychotherapy, and when this diagnosistreatment logic is applied to real life, problems quickly emerge. If the case conceptualization
is only informed by the diagnosis, what happens if a client presents with
polysymptomatology? In community settings, the patient population
often presents with comorbid psychological and physical disorders. Complexity and variability are customary, not the exception. Therefore, to provide the best treatment, where should the clinician start? What variables
should be considered and prioritized? Is the low-socioeconomic-status
Caucasian male patient suffering from chronic obstructive pulmonary disease, chronic pain, depression, and generalized anxiety to be treated with
the same psychological treatment as the high-income African American
woman with chronic pain, persistent depressive disorder, and anxiety not
otherwise specified?
Some researchers and clinicians have argued in favor of diagnosticdependent treatments (see Chambless et al., 1996, 1998). Probably the
most prolific approach in this area has been cognitive behavioural therapy (CBT) that has provided a plethora of disorder-specific treatment
protocols (see Beck, Rush, Shaw, & Emery, 1979; Leahy & Holland,
2000). Unfortunately, research has not supported this linear view (Miller,
Duncan, & Hubble, 2005; Wampold, 2010). First, the same disorder
seems to be treatable by a wide range of approaches. For example, depression and posttraumatic stress disorder can be effectively treated with
various intended-to-be therapeutic treatments (see Wampold, 2010 for a
discussion). Second, the same treatment can be efficacious for more than
one disorder. An illustration of this has been unified treatment protocols
For a more comprehensive discussion on treatment adherence see Wampold and Imel
(2015).
been validated using RCTs. According to Tucker and Roth (2006), there
seems to be this hierarchical views that favor randomized controlled trials (RCTs) over other forms of evidence (p. 101) to answer important
research questions (e.g., causal inferences) or inform of treatment efficacy. Janicek (2003, as cited in Tucker & Reed, 2008) refers to five levels
to classify evidence related to treatment efficacy: level 1 (RCTs), level 2
(nonrandomized trials), level 3 (analytical observational studies), level 4
(multiple times series, place comparisons, natural experiments), and
level 5 (expert opinions, case series or reports, descriptive occurrence).
It is clear that RCTs can produce valuable information and should not
be discarded (Hollon, 2006), but EBP cannot be reduced to the application of research produced by RCTs and should include other source of
evidence. Several authors have argued in favor of evidentiary pluralism
for EBP especially when applied to psychology (see Tucker & Roth, 2006;
Tucker & Reed, 2008) because some questions might be better investigated using other methodologies, such as case studies (Stiles, 2006b) or
process research studies (Greenberg & Watson, 2006 ). By focusing on
efficacy (superior or not) and neglecting variables related to the process of
change, RCTs do not help investigate what pertaining to the theoretical
model helped achieve symptom change (Greenberg & Watson, 2006).
Furthermore, more research is needed to determine if the results from
RCTs can be transported to real-life contexts with more heterogeneous
samples of clinicians and patients (Westen, 2006b). This seems especially
important for the usefulness of ESTs with ethnic minority groups, given
the scarcity of RCTs with this population (Sue & Zane, 2006).
The supremacy of RCTs is not only unfortunate for the advancement
of knowledge and treatment development but also for the publicly funded
treatments available to patients. As Reed (2006) noted, medical researchers and health care policy makers view the purpose of RCTs as providing
a basis for health policy (p. 17). In order to become an EST, the APAs
Division 12 (Clinical Psychology) established criteria (see Task Force on
Promotion and Dissemination of Psychological Procedures, 1993). To be
deemed well-established, the efficacy of the treatment must have been
demonstrated by at least two good between group design experiments
or a large series of single case design experiments (n>9) demonstrating
efficacy (Chambless et al., 1998, p. 4). Criteria also include the use of
10
11
outcome management systems have been developed (Outcome Questionnaire 45; Lambert et al., 2004; Clinical Outcomes in Routine Evaluation,
Core System Group, 1998; the Partners for Change Outcome Management System, Miller & Duncan, 2000; 2004) that are not dependent on
the nature of the psychological treatment being offered. In a field where
resources (both human and financial) are often limited, it is crucial that
clinicians be accountable to their client and third-party payers.
Putting It All Together: The Integrative Model
The main issues discussed in this chapter reveal the need for a good
case formulation model that permits clinical sensitivity, a model that
includes core ingredients being known to lead to change and permits
flexibility to consider the clients preferences, characteristics, and culture. This model should also be in constant evolution to incorporate
new research findings and should emphasize the need to monitor treatment outcomes. Lastly, this model should take into account the need
to evaluate competence in delivering such a model (versus the competence in delivering a particular treatment approach). This model should
be able to guide assessment, treatment planning, treatment delivery as
well as evaluation (treatment outcome and therapeutic competence). As
you embark on this discovery of psychotherapy integration, we wish to
offer some food for thoughts and encourage you to deliberate on your
own EBPP. Hopefully, you will find our integrative model useful in this
journey.
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Index
Alliance, behaviors, cognition,
dynamics, and existentials
(ABCDE) model, 6364
American Psychological Association
(APA), 2
Anxious symptomatology, 103
Assessment competency development
evaluating, 119
training goals for, 116119
Canadian Interprofessional Health
Collaborative (CIHC), 24
Capacity and self-care, 6971
Circle of care, 104
Client motivation, assessing, 105
Clinician-related variables
clinical case vignette, 5557
psychological assessment, 4041
Cognitive behavioural therapy
(CBT), 4
emotion-focused, 10
Competency-based evaluation, 119
Composite International Diagnostic
Interview (CIDI), 33
Contextual variables
clinical case vignette, 5557
psychological assessment, 4041
Depressive/anxious episodes, 97
Differential referral model, 21
DSM-5, 3
Dysregulation, avoiding, 96
Ecosystemic approach, psychological
assessment, 3537
case study for, 36
chronosystem, 3536
clinical case vignette, 5052
exosystem, 35
macrosystem, 35
microsystem, 35
ontosystem, 35
Emancipation, process of, 116
Emotion-focused CBT, 10
Empirically supported treatment
(EST), 69
Evidence-based medicine model, 23
Evidence-based practice (EBP)
and clinical competency
development, 115
clinicianpatient relationship, 5
definition of, 23
diagnosis as case formulation, 45
empirically supported treatment
(EST), 69
and integration, 911
main issues of, 3
to manualize evidence-based
treatment plans, 56
from medicine to psychology, 23
misconceptions of, 39
Presidential Task Force on, 2
Evidence-based practice in psychology
(EBPP), 2
Evidence-based treatment (EBT),
56, 62
Functional competencies, 20
Goal specificity, 117
Improving Access to Psychological
Therapies (IAPT) program, 8
Integrative assimilation, 22
Interdisciplinary collaboration
clinical case vignette, 5254
psychological assessment, 3739
Interprofessional collaboration
competency domains for
effective, 24
definition of, 24
Interprofessional competencies, 24
Interprofessional model
for psychological assessment, 3141
case formulation framework,
4142, 5759
140 INDEX
INDEX
141
142 INDEX
Treatment plan
creating, 7382
client feedback about, 112
client response to, 111
collaborative agreement
for, 112
planning session, 95112
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