Thoughts from Steve Welton

In 2020, the National Committee for Quality Assurance (NCQA) revealed a staggering figure of 40.3 million Americans aged 12 years or older who were grappling with a substance use disorder. This number equates to 14.5 percent of the population, highlighting a significant public health concern. Complementarily, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported in 2022 that 23.1 percent of the U.S. population had a mental illness, with a concerning overlap between those suffering from mental health disorders and substance use disorders.

The intersection of mental health and substance use disorders presents a complex challenge for healthcare providers. SAMHSA's findings that 21.5 million individuals had co-occurring disorders underscore the need for comprehensive screening and continuous monitoring throughout treatment. Despite the recognition of this dual diagnosis, the frequency and consistency of substance use assessment remain variably implemented across the board.

Crafting the "perfect" progress note is a common challenge among clinicians, often bogged down by the struggle of choosing the right words to accurately describe therapy sessions. This challenge encompasses the need to succinctly document the client's condition outside the therapy room, the interactions and progress made within the session, and an overall assessment of the client's response to treatment. Utilizing technical language not only aids in capturing these elements with greater precision but also streamlines the documentation process, making progress notes more efficient and effective.

The inclination to describe a client's experience in detail, as opposed to using concise technical terms, is understandable yet it prolongs the documentation process. For instance, opting to use 'ruminated' instead of detailing every thought a client had, or 'dysthymia' instead of describing long-term low depression levels, saves time without sacrificing the quality of the progress notes. The essence of integrating technical language into progress notes lies in achieving brevity without losing the depth and accuracy of client assessments and therapy outcomes.

For clinicians not yet comfortable with technical jargon, simple strategies such as creating a personal glossary or paying extra attention to the language used in continued education courses could enhance their documentation skills. Embracing technical language doesn't just streamline documenting processes; it significantly enriches the clinician's approach to treatment planning, client assessment, and overall perception of clinical work. This shift not only elevates the quality of client care but also empowers clinicians with a more structured and focused approach to therapy documentation.

The clinical formulation, once a staple of the treatment record, has become less prevalent in contemporary clinical practice. This tool extends beyond the limitations of diagnosis-focused approaches like the DSM-5, offering a narrative method that encompasses the biopsychosocial aspects of a patient's condition. It enables clinicians to identify symptoms and deficits within the broader context of the patient's life, enhancing the planning and direction of treatment.

Central to the clinical formulation is its ability to bridge the gap between assessment and treatment. By synthesizing information from questionnaires, interviews, and standardized instruments, it establishes the necessity for therapy and charts a focused course for intervention. This approach is particularly beneficial in crafting treatment plans for conditions like depression, where understanding the interplay between thoughts, behaviors, and emotions is crucial.

Emphasizing its value, the clinical formulation serves multiple purposes: it justifies the medical necessity of treatment, provides a clear starting point for therapy that both clinician and client can understand, and acts as a reference point to maintain focus during the therapeutic process. Despite perceptions of it being time-consuming, the formulation is an invaluable asset in clinical practice, offering a structured guide through the complexities of treatment planning and execution.

Access to mental health care in the United States is challenged by a disparity largely influenced by an individual's financial capacity. Despite the prevalence of mental illness, with one in five adults living with a condition, treatment remains out of reach for many due to cost concerns or lack of insurance coverage. The situation is exacerbated for those experiencing additional stressors such as low income, insecure housing, or limited transportation, making access to affordable mental health services even more critical.

Addressing this issue extends beyond urban centers, touching rural communities where logistics and distance further hinder the delivery of care. Mental health inequities have tangible effects on various demographics, including higher suicide rates among indigenous populations and delayed diagnoses for children with autism in marginalized groups. Achieving mental health equity is paramount, requiring a systemic shift to ensure everyone has the opportunity to reach their full health potential, irrespective of their socio-economic status.

Peer-based services, a concept deeply rooted in the realm of mental health and substance use recovery, extend beyond traditional therapeutic interventions to offer a unique and empowering form of support. Originating from the 1970s self-help movement, these services leverage the lived experiences of individuals who have navigated similar challenges, offering not just emotional support but also practical guidance, skill teaching, and connections to further resources. Unlike the more clinical aspects of recovery, peer services provide a non-coercive and consumer-driven approach, allowing individuals to take control of their recovery journey with the support of someone who truly understands.

For professionals in private or group practice who provide services to individuals in the Medicaid population, peer-based services can represent a critical resource that enriches the spectrum of care available to those in need. They offer a pathway for individuals to not only receive support from someone with shared experiences but also to feel a greater sense of empowerment and connection within their community. As the conversation around mental health continues to evolve, the role of peer services stands out as a testament to the power of empathy, shared experience, and community in fostering recovery and resilience. 

Exploring the inclusion of the biomedical component in the biopsychosocial assessment, this piece discusses its vital role in understanding a client's overall well-being. It asserts that psychotherapists, despite not being medically trained, can gain deep insights into a client's physical health and its impact on their mental state and behavior. By assessing the physical health alongside psychological and social factors, therapists can approach treatment with a comprehensive understanding of the person they are helping.

The concept of Medical Necessity in the realm of psychotherapy represents a crucial, yet often overlooked, aspect in the documentation and audit processes within healthcare. This concept serves as the cornerstone of therapeutic intervention, guiding the "what" and "why" of our actions from the initial to the final session with a client. It demands an objective evaluation of treatment documentation to ensure that the reasons for psychotherapy are both justified and clearly articulated, emphasizing that Medical Necessity involves much more than a mere statement in a progress note but is fundamental to the essence of psychotherapeutic work.

Navigating the world of behavioral health can often feel like walking on eggshells, especially with the ever-present fear of audits by insurance companies. For many clinicians, the idea of an audit looms large, stirring anxiety and countless questions. Yet, it's essential to know that audits come in various forms, each with different focuses such as claims validation, service review, or quality of care. Understanding the specific nature of an audit can significantly reduce the anxiety surrounding it, empowering clinicians to prepare adequately.

Preparing for an audit shouldn't be a cause for panic. With proper recordkeeping and understanding the type of audit at hand, clinicians can navigate this process more confidently. Many find that with the right preparation, including maintaining comprehensive treatment records and responding promptly to audit requests, the outcome can be far less frightening than anticipated. Being audit-ready not only reduces anxiety but also reinforces the quality and integrity of the clinical practice.

Subjective material in progress notes, often encapsulated in the SOAP (Subjective, Objective, Assessment, and Plan) documentation method, tends to be a misunderstood yet critical component of client records. Unlike objective data, which is based on observable facts, subjective content revolves around a client's personal experiences, feelings, and beliefs. This distinction is important for healthcare professionals to grasp because it involves capturing the essence of a client’s personal narrative and how they are navigating the world with the skills and perspectives gained from therapy.

It’s crucial to understand that the subjective portion of progress notes should not aim to record every detail of a client's life outside therapy but rather focus on how they are applying therapeutic strategies in real-life situations. This includes their responses to various events, the use of skills learned in therapy, and the current symptoms or challenges they face. These insights provide invaluable context for the treatment's trajectory, highlighting both progress and ongoing areas of need.

The increasing prevalence of depression and anxiety among the U.S. population, especially following recent social upheavals, highlights the critical role standardized assessments play in behavioral health treatment. With around half of young adults reporting symptoms and a significant portion of the U.S. undergoing anxiety or depression annually, these tools not only assist in identifying these conditions at the onset of therapy but also serve the expectations of community and third-party payers for thorough initial assessments. The validity and effectiveness of these assessments, such as the Patient Health Questionnaire (PHQ) 9 and the Beck Depression Inventory (BDI-II), are underpinned by peer review and continuous evaluation, making them reliable resources in diagnosing and managing mental health.

Among the advantages of standardized assessments are their ability to be self-administered, saving time for both the clinician and the client, and their validation across various age groups. Tools like the PHQ-9 and the Generalized Anxiety Disorder (GAD)-7 questionnaire are lauded for their brevity and efficacy, capable of effectively assessing degrees of depression and anxiety. These instruments ensure a uniform approach to understanding clients' symptoms, facilitating a baseline from which to measure progress or identify deterioration over time.

Incorporating these standardized tools into clinical practice offers a structured and efficient means of symptom assessment and monitoring, critical for those accepting health insurance reimbursements. The ease of use, supported by most Electronic Health Records (EHR) systems that automate the administration and record-keeping of these assessments, adds to the appeal of integrating these measures into ongoing patient care. Clinicians are encouraged to utilize these assessments consistently, leveraging their proven effectiveness to better identify and address the mental health needs of their clients.

A recent study from the National Institutes of Health (NIH) found that Cognitive Behavioral Therapy (CBT) can improve clinical symptoms and brain function in children with anxiety. The study, titled "Cognitive Behavioral Therapy Alters Brain Activity in Children with Anxiety," revealed the effectiveness of CBT as a treatment for anxiety and depression. The findings highlight the importance of evidence-based practice and the ongoing research that supports it. This serves as a reminder for therapists to stay informed about the treatments they employ, understanding the potential risks and side effects associated with different modalities. By being aware of the limits and potential outcomes, therapists can ensure the best possible outcomes for their clients.

Completing a comprehensive assessment of a client's social history is crucial in the biopsychosocial assessment process at the beginning of treatment. The environment in which a person grows up has a significant impact on their adult life, and understanding those formative years is key to understanding present issues. Family relationships, as highlighted in an article published in "Innovations and Aging," play a central role in an individual's well-being throughout their life, creating both positive and negative structures that affect their psychosocial, behavioral, and psychological health. The stress process, consisting of stressors, moderators, and outcomes, further emphasizes the importance of understanding a client's social stress in the development of mental health disorders. While it may take time for clients to open up about their social history, initiating the conversation during the initial interview can introduce its value to the therapeutic process.

Many clinicians struggle with creating effective treatment plans, particularly when it comes to constructing interventions. Goals are the first part of a treatment plan, representing what will be achieved through treatment. Objectives are smaller milestones that lead to the goals. Interventions, on the other hand, are the specific actions taken during therapy sessions to help clients achieve their goals. They should be specific and action-oriented, rather than just stating the type of therapy being used. An example of a client with depressive symptoms is used to illustrate the importance of identifying and addressing cognitive distortions through processing and teaching techniques. Treatment plans should be clear, detailed, and concise to ensure they are actually used effectively.

The author emphasizes the need for specific and action-oriented interventions in the treatment plan. Simply stating the use of a particular therapy modality is not sufficient. Instead, interventions should be tailored to address the specific symptoms and deficits identified during the assessment process. The article provides an example of a client with depressive symptoms and discusses interventions related to addressing negative self-talk and cognitive distortions.

The Zero Suicide program aims to effectively eliminate completed suicides by improving access to services and the quality of those services. It takes a systemic approach and emphasizes evidence-based practices to treat individuals at risk for suicide. With suicide being a significant cause of death among young individuals, it is crucial for clinicians to be trained in effectively addressing and managing suicidal thoughts and behaviors. The Zero Suicide website offers various resources and training recommendations to support this goal.

Handwriting progress notes can have a positive impact on our brains, but the challenge arises when we need to transfer them to electronic health records (EHR). The solution? Utilizing tablets and stylus technology. 

This blog post highlights the importance of understanding the rules and responsibilities related to documentation retention for treatment records. While electronic health records (EHR) have reduced the need for physical file cabinets, it is crucial not to rely solely on EHR vendors for the retention of records. 

The importance of conducting a medical history assessment as a clinician, even if you are not a physician, is highlighted in a recent blog post. With the prevalence of Long COVID, an estimated 7.7 to 23 million people in the United States are currently living with cognitive impairments, depression, anxiety, and insomnia stemming from Post-COVID-19 illness. While ongoing studies seek to understand the underlying mechanisms of Long COVID, it is crucial for behavioral health clinicians to recognize and assess for these potentially long-term impacts. Dismissing Long COVID as a psychosomatic condition can have negative mental health consequences, so it's vital to be aware of your clients' prior COVID-19 diagnosis and adjust treatment plans accordingly.

In this blog post, the writer emphasizes the importance of managing clinical documentation standards in a practice, particularly when dealing with provisionally licensed clinicians or those who struggle with documentation. 

This blog post discusses the importance of properly addressing and fixing errors made in treatment records. It emphasizes the need to keep the original entry visible and legible, regardless of whether the records are handwritten or electronic. 

In a recent blog post, the challenge of defining medical necessity in psychotherapy for clients using insurance is discussed. Many clinicians struggle to determine "what the insurance company wants." The author suggests that a strong presenting problem section at the beginning of the assessment can be a helpful first step in establishing medical necessity. This section should address the who, what, where, how, and why of the client's symptoms and concerns. By focusing on the primary elements that establish the basis of medical necessity, clinicians can create a context for the treatment plan. While the presenting problem is not the entirety of medical necessity, it can be a significant factor in less complex cases.