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Maximizing Effectiveness in Dynamic Psychotherapy Self-Compassion in Psychotherapy101 Healing StoriesA Clinician's Guide to Legal Issues in PsychotherapyA Map of the MindA Primer for Beginning PsychotherapyACT With LoveActive Treatment of DepressionAffect Regulation, Mentalization, and the Development of SelfAlready FreeBad TherapyBecoming an Effective PsychotherapistBefore ForgivingBeing a Brain-Wise TherapistBetrayed as BoysBeyond Evidence-Based PsychotherapyBeyond MadnessBeyond PostmodernismBinge No MoreBiofeedback for the BrainBipolar DisorderBody PsychotherapyBoundaries and Boundary Violations in PsychoanalysisBrain Change TherapyBrain Science and Psychological DisordersBrain-Based Therapy with AdultsBrain-Based Therapy with Children and AdolescentsBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Therapy Homework PlannerBuffy the Vampire Slayer and PhilosophyBuilding on BionCare of the PsycheCase Studies in DepressionCaught in the NetChild and Adolescent Treatment for Social Work PracticeChoosing an Online TherapistChronic DepressionClinical Dilemmas in PsychotherapyClinical Handbook of Psychological DisordersClinical Intuition in PsychotherapyClinical Pearls of WisdomCo-Creating ChangeCognitive Therapy for Challenging ProblemsCompassionConfessions of a Former ChildConfidential RelationshipsConfidentiality and Mental HealthConfidingContemplative Psychotherapy EssentialsControlConversations About Psychology and Sexual OrientationCoping with BPDCouch FictionCounseling in GenderlandCounseling with Choice TheoryCouple SkillsCrazy for YouCreating a Life of Meaning and CompassionCreating HysteriaCritical Issues in PsychotherapyCrucial Choices, Crucial ChangesDeafness In MindDecoding the Ethics CodeDeconstructing PsychotherapyDeep Brain StimulationDemystifying TherapyDepression 101Depression in ContextDialogues on DifferenceDissociative ChildrenDo-It-Yourself Eye Movement Techniques for Emotional HealingDoing CBTE-TherapyEarly WarningEncountering the Sacred in PsychotherapyEnergy Psychology InteractiveErrant SelvesEssays on Philosophical CounselingEssentials of Wais-III AssessmentEthically Challenged ProfessionsEthics and Values in PsychotherapyEthics in Plain EnglishEthics in Psychotherapy and CounselingExpectationExploring the Self through PhotographyExpressing EmotionFacing Human SufferingFairbairn's Object Relations Theory in the Clinical SettingFamily TherapyFavorite Counseling and Therapy Homework AssignmentsFear of IntimacyFlourishingFolie a DeuxForms of Intersubjectivity in Infant Reasearch and Adult TreatmentFoundations of Ethical Practice, Research, and Teaching in PsychologyFreud and the Question of PseudoscienceFrom Morality to Mental HealthFundamentals of Psychoanalytic TechniqueGenes on the CouchGod & TherapyHalf Empty, Half FullHandbook of Clinical Psychopharmacology for TherapistsHandbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual ClientsHandbook of Evidence-Based Therapies for Children and AdolescentsHealing the Heart and Mind with MindfulnessHeinz KohutHelping Children Cope With Disasters and TerrorismHigh RiskHistory of PsychotherapyHow Clients Make Therapy WorkHow Psychotherapists DevelopHow to Fail As a TherapistHow to Go to TherapyHypnosis for Inner Conflict ResolutionHypnosis for Smoking CessationI Never Promised You a Rose GardenIf Only I Had KnownIn Others' EyesIn SessionIn Therapy We TrustIn Treatment: Season 1Incorporating Spirituality in Counseling and PsychotherapyInside the SessionInside TherapyIs Long-Term Therapy Unethical?Issues in Philosophical CounselingIt's Not as Bad as It SeemsItís Your HourLearning from Our MistakesLearning Supportive PsychotherapyLetters to a Young TherapistLife CoachingLogotherapy and Existential AnalysisLove's ExecutionerMadness and DemocracyMaking the Big LeapMan's Search for MeaningMetaphoria: Metaphor and Guided Metaphor for Psychotherapy and HealingMind GamesMindfulness and AcceptanceMindfulness-Based Cognitive Therapy for DepressionMindworks: An Introduction to NLPMockingbird YearsMoments of EngagementMomma and the Meaning of LifeMotivational Interviewing: Preparing People For ChangeMulticulturalism and the Therapeutic ProcessMultifamily Groups in the Treatment of Severe Psychiatric DisordersNarrative PracticeOn the CouchOne Nation Under TherapyOur Inner WorldOur Last Great IllusionOutsider ArtOvercoming Destructive Beliefs, Feelings, and BehaviorsOverexposedPathways to SpiritualityPersonality and PsychotherapyPhilosophical CounselingPhilosophical Counselling and the UnconsciousPhilosophical Issues in Counseling and PsychotherapyPhilosophical PracticePhilosophy and PsychotherapyPhilosophy for Counselling and PsychotherapyPhilosophy PracticePhilosophy's Role in Counseling and PsychotherapyPillar of SaltPlan BPlato, Not Prozac!Polarities of ExperiencesPower GamesPractical Psychoanalysis for Therapists and PatientsPrinciples and Practice of Sex TherapyPsychologists Defying the CrowdPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychosis in the FamilyPsychotherapyPsychotherapyPsychotherapy and ConfidentialityPsychotherapy As PraxisPsychotherapy for Children and AdolescentsPsychotherapy for Personality DisordersPsychotherapy Is Worth ItPsychotherapy Isn't What You ThinkPsychotherapy with Adolescent Girls and Young WomenPsychotherapy with Children and AdolescentsPsychotherapy without the SelfPsychotherapy, American Culture, and Social PolicyRapid Cognitive TherapyRational Emotive Behavior TherapyRational Emotive Behavior TherapyRationality and the Pursuit of HappinessRebuilding Shattered LivesReclaiming Our ChildrenRecovery OptionsRelationalityRent Two Films and Let's Talk in the MorningSaving the Modern SoulScience and Pseudoscience in Clinical PsychologySecond-order Change in PsychotherapySelf-Compassion in PsychotherapySelf-Determination Theory in the ClinicSelf-Disclosure in Psychotherapy and RecoverySerious ShoppingSex, Therapy, and KidsSexual Orientation and Psychodynamic PsychotherapySigns of SafetySoul Murder RevisitedStaring at the SunStraight to JesusStrangers to OurselvesSubjective Experience and the Logic of the OtherTaking America Off DrugsTales of PsychotherapyTales of UnknowingTalk is Not EnoughTalking Cures and Placebo EffectsTelling SecretsThe Behavioral Medicine Treatment PlannerThe Body in PsychotherapyThe Brief Couples Therapy Homework Planner with DiskThe Case Formulation Approach to Cognitive-Behavior TherapyThe Challenge for Psychoanalysis and PsychotherapyThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Couch and the TreeThe Couples Psychotherapy Treatment PlannerThe Crucible of ExperienceThe Cure of SoulsThe Death of PsychotherapyThe Education of Mrs. BemisThe Ethical Treatment of DepressionThe Ethics of PsychoanalysisThe Gay and Lesbian Psychotherapy Treatment PlannerThe Gift of TherapyThe Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work The Healing JourneyThe Heart & Soul of ChangeThe Heroic ClientThe Husbands and Wives ClubThe Love CureThe Making of a TherapistThe Mindful TherapistThe Mirror Crack'dThe Mummy at the Dining Room TableThe Neuroscience of PsychotherapyThe Neuroscience of Psychotherapy: Healing the Social BrainThe New Rational TherapyThe Older Adult Psychotherapy Treatment PlannerThe Other Side of DesireThe Pastoral Counseling Treatment PlannerThe Philosopher's Autobiography The Pornographer's GriefThe Portable CoachThe Portable Ethicist for Mental Health Professionals The Present Moment in Psychotherapy and Everyday LifeThe Problem of EvilThe Problem with Cognitive Behavioural TherapyThe Psychodynamics of Gender and Gender RoleThe Psychotherapy Documentation PrimerThe Psychotherapy Documentation PrimerThe Psychotherapy of HopeThe Real World Guide to Psychotherapy PracticeThe Schopenhauer CureThe Sex Lives of TeenagersThe Talking CureThe Therapeutic "Aha!"The Therapist's Guide to PsychopharmacologyThe Therapist's Guide to Psychopharmacology, Revised EditionThe Therapist's Ultimate Solution BookThe Trauma of Everyday LifeThe UnsayableThe Way of the JournalTheory and Practice of Brief TherapyTherapy with ChildrenTherapy's DelusionsTheraScribe 3.0 for WindowsTheraScribe 4.0Thinking about ThinkingThinking for CliniciansThinking for CliniciansThoughts Without a ThinkerThriveToward a Psychology of AwakeningTracking Mental Health OutcomesTrauma, Truth and ReconciliationTreating Attachment DisordersTreatment for Chronic DepressionTreatment Plans and Interventions for Depression and Anxiety DisordersUnderstanding Child MolestersUnspeakable Truths and Happy EndingsWhat the Buddha FeltWhat Works for Whom?What Works for Whom? Second EditionWhen the Body SpeaksWhispers from the EastWise TherapyWittgenstein and PsychotherapyWorking MindsWoulda, Coulda, ShouldaWriting About PatientsYoga Skills for Therapists:Yoga Therapy

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The Clinical Documentation SourcebookReview - The Clinical Documentation Sourcebook
A Comprehensive Collection of Mental Health Practice Forms, Handouts, and Records (Second Edition)
by Donald E. Wiger
John Wiley & Sons, 1999
Review by Kelly Lemmon-Kishi
Jun 14th 1999 (Volume 3, Issue 24)

Smart Paperwork

The Clinical Documentation Sourcebook delivers exactly what it promises on the cover - ready to use forms for managing every stage of the treatment process - "all the forms … and records a mental health professional needs to meet the documentation requirements of the managed care era". You may also learn to respect (if not exactly love) your paperwork, thanks to Wiger's concise explanations. Reminders of the purpose and logic behind each form help - but time saving form design and techniques as well as tips for improved managed care savvy make this book a worthy investment for organizations and private practices. The perfectly formatted, easy to use disk is the icing on the cake - another time saver (but only for those using Windows).

However, there are some major typos! "Liability" instead of "lability," and "fool intolerance" for "food intolerance",…. PROOF READ VERY CAREFULLY before using these documents.

Each chapter begins with a brief explanation and rationale for each form. The author's positive position on the importance of paperwork can help reframe chores into useful tools that work for you, the clinician, as well as 3rd party payers and regulators - and can ultimately benefit your clients. The author notes which forms specifically meet JCAHO requirements. Useful suggestions will also help clinicians avoid some fairly common types of unintentional insurance fraud and potential violations of confidentiality as well as increase success rates in obtaining Prior Authorization from 3rd party payers. Samples of completed forms demonstrate good and bad approaches to paperwork.

Chapter 1 contains intake and termination forms and procedures, including initial client intake form, financial policy statement, payment contract for services, limits of confidentiality form, credit card authorization, release of information consent form, suicide prevention contract, discharge summary form, and a sample termination letter. All of the forms that clients fill out are relatively easy to understand (high school reading level); they are designed to make all aspects of the financial and legal relationship between clinic and client as clear as possible so they are rather long. I particularly like the "limits of confidentiality form" - it is clear, comprehensive, jargon-free and explains the limits of confidentiality thoroughly - but it takes 2 pages!

Chapter 2 contains a series of assessment forms and some assistance in determining which forms are appropriate for which situations. Initial assessment forms, biographical information forms, and personal history forms for both adults and children are included. In addition there are forms for emotional/behavioral assessments, emotional/behavioral updates, biopsychosocial reports, diagnostic assessment reports, and diagnostic assessments for lower functioning clients.

Chapter 3 contains complete forms for performing adult and child psychological evaluations - but no directions. The author refers those unfamiliar with the intricacies of psych-evaluations to his Psychotherapy Documentation Primer (Wiger, 1999, also published by Wiley).

Treatment planning is dealt with in Chapter 4. After two pages outlining the process for developing effective (for client, for agency, for reimbursement) are forms for standard individual and short term therapy treatment planning. These are followed up with treatment review and update forms.

Chapter 5 covers progress notes and prior authorization requests. Wiger's system leads to excellent progress notes that can be done quickly during the session. The form for group therapy progress notes is notable for speed and ease of use, comprehensiveness, good organization, and protection of each client's confidentiality. The sample clinical outcomes questionnaire (to assess consumer satisfaction) and chart review forms (to assess clinician's record keeping) will provide valuable information. The chart review form allows for objective quantifiable assessment of the quality of a client's records that should help make chart reviews constructive learning experiences.

The final chapter includes comprehensive information gathering forms for married and unmarried couples and three good handouts/exercises for couples. Both of the couples information forms are 5 pages and cover much of the same information: current situation, children, areas of satisfaction/dissatisfaction, expectations, allocation of household responsibilities, argument style and responses, and a confidentiality waiver so that the information can be shared during joint sessions. Clients fill out the forms. There are again a few serious typos, though, such as forgetting to change the word "marriage" to "relationship," so proof read these forms carefully before handing them to clients.

The book cover exaggerates when it promises "all the forms, handouts, and records a mental health professional needs…" All is forgiven, though, because all three handouts for couples are excellent. "Cooperating in Child Rearing" is two pages of information, suggestions, and directions followed by three pages of questions; it is very thorough and leads clients through the process of beginning to analyze how their childhood experiences influence their current parenting instincts as well as encouraging cooperation. "Sharing your feelings" is a sentence completion task to jump start emotional sharing, listening, and empathy. The "analysis of target behaviors" asks partners to track problematic behaviors, then analyze the cause, resulting feelings, and "what positive actions could have been taken" to change the outcome.

This is a nice collection, but it needs better proofreading. Thank goodness for the disk!
 


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