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DOCUMENTATION PRIMER 4th Edition

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The Psychotherapy
Documentation Primer
Fourth Edition
The Psychotherapy
Documentation
Primer
Fourth Edition
Donald E Wiger
This edition first published 2021
© 2021, John Wiley & Sons, Inc.
4th Edition
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Library of Congress Cataloging-in-Publication Data
Names: Wiger, Donald E., 1953- author.
Title: The psychotherapy documentation primer / Donald E. Wiger.
Description: Fourth edition. | Hoboken, NJ : John Wiley & Sons, Inc.,
[2021] | Includes bibliographical references and index.
Identifiers: LCCN 2020021962 (print) | LCCN 2020021963 (ebook) | ISBN
9781119709848 (paperback) | ISBN 9781119709923 (adobe pdf) | ISBN
9781119709930 (epub)
Subjects: LCSH: Psychiatric records. | Mental health services—Medical
records. | Mental health services—Management.
Classification: LCC RC455.2.M38 W543 2021 (print) | LCC RC455.2.M38
(ebook) | DDC 616.890068—dc23
LC record available at https://lccn.loc.gov/2020021962
LC ebook record available at https://lccn.loc.gov/2020021963
Cover Design: Wiley
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10 9 8 7 6 5 4 3 2 1
Contents
Preface vii
How This Book Came Into Being: A Lesson in Making
a Really Bad Negative into a Really Good Positive ix
1 Introduction 1
2 The Art and Science of Psychological Assessment and Treatment 9
3 Overview of Current Documentation Procedures and Third-Party
Requirements 15
4 Ethical Considerations in Documentation 45
5 The Biopsychosocial Assessment 59
6 The Clinical Interview: Mental Status Exam 93
7 The Clinical Interview: Validating a Diagnosis 111
8 Formulating a Treatment Plan 135
9 Writing Progress Notes 163
10 Documenting the Need for Additional Services 195
11 Documenting Mental Health Treatment Outcomes for Individuals 201
Appendix A Putting it all Together: Documented

Chart for Mental Health Services 213
Appendix B Overview of HIPAA Guidelines in Mental Health
Settings 233
Appendix C Example of Corrective Actions Due to a Therapist’s
Poor Documentation 237
Appendix D Documenting Suicidality 241
Glossary 245
References and Suggested Readings 253
Index257
v
Preface
T
he Psychotherapy Documentation Primer is designed to teach documen-
tal skills for the course of psychotherapy from the initial interview to
the discharge. The major revisions from the previous edition are due
to changes from the Diagnostic and Statistical Manual of Mental Disorders
(DSM)-IV-TR to the DSM-5 and more safeguards from potential procedural
errors and omissions. An appendix on documenting suicidality has also been
added.
The readership is intended for both students and professionals in the men-
tal health field. Several graduate schools have incorporated this text in courses
in which students learn to document clear evidence validating a diagnosis,
effects of psychotherapy, treatment planning, and outcomes. Several expe-
rienced mental health professionals have written that the training has been
quite helpful learning documentation techniques in which they had never
been taught. Graduate training in mental health covers a broad education in
several areas of psychology, psychotherapy, and other subjects related to the
helping professions, but all too often, it does not provide detailed training in
documentation techniques.
The documentation principles discussed in this text are especially helpful in
satisfying the often rigid requirements of third parties, such as insurance com-
panies and regulating agencies. In addition, the same documentation require-
ments satisfy what is typically required by mental health licensing boards.
Documentation, on the surface, appears to be a fairly dry subject. However,
those who learn empirical and succinct documentation techniques find that
the time they spend on this task reduces the time devoted to paperwork. Doc-
umentation is much more than basic “paperwork.” It provides clear evidence
of the effects of mental health treatment. One does not have to be in the field
very long until they experience an audit in which the only evidence avail-
able is what is documented. Documentation skills are an extremely important
aspect of being a therapist.
The first edition covered documentation in the basic areas of clinical ser-
vice. It was well received primarily because there wasn’t much published
vii
viii Preface
on this topic. The second edition was published shortly after several Health
Insurance Portability and Accountability Act (HIPAA) procedures were nec-
essary to document; additional examples were provided. The third edition
provided the same basic paradigms of documentation as the previous edi-
tions, with two additional chapters: (a) The Art and Science of Psychological
Assessment and Treatment, and (b) Ethical Considerations in Documenta-
tion. The current edition incorporates diagnostic criteria of the DSM-5 and
adds a chapter on documenting clinical outcomes and an additional appen-
dix on documenting suicidality.
Donald E. Wiger
How This Book Came Into Being:
A Lesson in Making a Really Bad Negative
Into a Really Good Positive
I
n 1991, I started a solo mental health practice with no clients, very little
money, no office furniture, and no formal business training. However,
I had a surplus of enthusiasm and dedication. I found a three-room office
suite that had been vacant for over a year, so I figured that I could get a
fairly good deal on the rent. The sympathetic, but also hungry landlord and
I worked out a deal in which I wouldn’t have to pay rent for the first few
months. He had nothing to lose because there had been no renters for over a
year. He was glad just to have a renter. The furniture for the office came from
my home. “Open for business!”
I did not take with me any of my clients whom I had seen from my former
employer. I considered that to be an unethical practice. Instead, I transitioned
them to other therapists when I left the practice. Of course, there can be excep-
tions to this rule, but be careful in such cases. I have seen too many thera-
pists start their own practices by taking their clients with them from another
agency. Over the years, I have witnessed many ill feelings between employers
and ex-employees who “took their clients” with them, often without notice!
This can cause much financial havoc for a clinic that has spent an incredible
amount of time, money, and effort to build their practice. Bottom line: Cover
such concerns in an initial contract with the employee or contractor. Be sure
to use an attorney with plenty of expertise in this area. A relatively small
investment up front could save your practice and reputation in the future. It
can be difficult to have balance between being both in business and being in
the helping profession.
To get started, I spent the remainder of my savings and much time estab-
lishing a counseling practice by scheduling talks with different groups,
sending out mailers to several organizations, and letting other mental health
professionals, with whom I had dealt previously, know that I had started a
private practice. Many referrals came from other therapists who had a full
ix
x How This Book Came Into Being
case load, in which they were glad to have a place to send people in need of
services. Even my previous employer sent referrals my way.
Fortunately, growth took place quickly, and within the first year there were
two additional full-time employees. The rate of growth skyrocketed because
we incorporated progressive, but ethical business principles and emphasized
customer service. Now we could afford nice furniture at home and at the
office!
Unfortunately, even though our clinic was on the right track, our quick
growth caught the eye of an insurance auditor. Our rather sudden volume of
business led to high payments from Medicaid. Because the amount of billing
skyrocketed from nothing to quite high in a few years, we were a red flag for
an audit. When I received notice of an audit I wasn’t worried because we had
records for every client and most likely underbilled rather than overbilled. So,
a few weeks later, when the auditors showed up for their scheduled review,
we were naively proud to show them that there were indeed their requested
intake notes, treatment plans, and progress notes. I had written them the
same way in which I was trained, so they must be pretty good!
The finding that complete records existed for every client and the rapid
growth of the clinic was never mentioned as a positive by the auditors. We
weren’t sure what they were attempting to find in our client records. The
auditors copied multiple files and informed us that we would hear from them
in about a month. Because they gave us no immediate feedback, we weren’t
sure whether when they returned we would receive accolades or reprimands.
But, we were quite confident that all was well.
For the next month, we did business as usual and didn’t think much about
the audit. However, when they showed up for the feedback session, our lives
soon changed. The auditors informed us that there were no financial impro-
prieties, and there were no records missing. We had not billed for any dates
of service in which there were no records and we had not overbilled for any
procedures. So far . . . so good. But, then they opened their briefcases with
seemingly hundreds of progress notes in which they said were “not in com-
pliance.” My initial thoughts were, “not in compliance with what?” I was not
taught a specific way to write progress notes in my graduate training, my
internship, or my previous employment. I simply wrote down what we did
in the session, just like at my previous job. But, they had never been audited!
My problem was that I didn’t know what I didn’t know, which is commonly
called “ignorance.” The old saying, “Ignorance of the law is no excuse” was
now staring me in the face. I soon learned that other old adage, “Ignorance is
bliss,” is not true.
The auditors kindly and respectfully explained that our progress notes
stunk. Their point was that just because services took place, it doesn’t mean
How This Book Came Into Being xi
that there is documented evidence that psychotherapy was necessary. They

unsympathetically admonished me that psychotherapy records must docu-
ment medical necessity. I had never heard of this term. It sounded like some-
thing someone would say in a medical office, not a counseling clinic. I thought
to myself, “Medical necessity: We don’t provide medical services.” They went
on to say that even though the assessments adequately explained the clients’
diagnoses, the progress notes did not recurrently confirm the diagnosis,
reflect the effects of treatment, follow a specific measurable treatment plan,
and need for continued treatment. My progress notes merely documented
that treatment took place with some comments of what took place in the ses-
sions. This was not enough.
They explained to me that the documented content of each session must
match the goals and objectives written in the treatment plan. I had never
heard of treatment plan goals and objectives the way in which they viewed
them. Their main point was that my progress notes for every session did not
clearly describe ongoing symptoms and impairments that should be listed
in the intake notes and treatment plan. That is, every progress note should
validate the current need for services and the services performed must be
appropriate for the client’s problem areas. Even if a client is severely impaired
mentally, if it is not documented in every progress note, there is no evidence
for the need for psychotherapy. They repeatedly emphasized, “If it isn’t writ-
ten down it doesn’t exist.” I wasn’t taught this in graduate school, nor in my
initial employment.
I was told that I must pay back Medicaid the amount that I was paid for
every progress note that did not meet this criterion. Although our treatment
was appropriate and our clients’ outcomes were positive, our progress notes
did not specifically address medical necessity. Even if services were medi-
cally necessary, if it wasn’t clearly documented, it didn’t matter to them.
Our documentation covered the contents of the sessions only. Bottom line:
We provided documentation; but it was the wrong documentation. Perhaps
we should have spent more time reading their bulky manual. I was convinced
that we provided life-changing mental health services, but the documentation
didn’t provide the evidence the auditors required. We had done nothing clini-
cally, morally, or ethically wrong, but documentation is not about such skills; it
is about supplying empirical evidence. Being a good therapist was not enough.
What surprised me even more was that they didn’t ask for a payback for
only the records that they had audited. They stated that because they audited
one quarter of the records that I would have to pay back four times the amount
of records that they had deemed not fitting their standards. Ouch!
This lack of appropriate documentation cost me several thousand dol-
lars in paybacks to Medicaid. Fortunately, they put me on a payment plan;
xii How This Book Came Into Being
otherwise, we would have gone out of business. At the time the effects of this
audit seemed like the worst thing that could have happened to me. I had no
one to blame but myself. I couldn’t tell the auditors that it wasn’t my fault
because no one had taught me how to appropriately document psychother-
apy; because as a mental health professional it was my responsibility to be
accountable for learning the procedures expected from me.
What surprised me, even more, was that the auditors weren’t mental health
professionals. They were trained in clerical areas. Although it took a while for
me to make the connection, I eventually woke up to realize that if people not
even trained in our profession can learn mental health documentation, I cer-
tainly had no excuses. This insight did not take place overnight!
The lessons learned from the audit inspired me to learn everything I could
about documentation of mental health services. I studied information availa-
ble from accreditation agencies, provider manuals from insurance companies,
journal articles, and a few texts that existed at the time. With this informa-
tion I revised our clinical forms to make sure that the information obtained
accurately covered what was required. After sharing this information with
colleagues, I was asked to present local seminars. This eventually led to pre-
senting this material in several seminars nationally, teaching documentation
skills. Before I knew it, my forms were published. The forms book is currently
in its fourth edition (Wiger, 2010), and I’m working on the next edition. The
auditors clearly did me a favor!
Now I’m glad that my clinic was audited. It changed my life! A negative
experience transformed into something quite positive. Now, when I hear fel-
low clinicians complain about auditors and insurance companies, I don’t nec-
essarily agree with them.
I have learned that when either an evaluation or therapy is being con-
ducted, with a “documentation frame of mind,” the treatment is much more
on target. It keeps me from getting off track with clients. It helps keep the
intervention focused, in which time is not wasted time with the client. I have
heard too many clients complain that, in their previous counseling, they did
too much chit-chat and not enough therapy. Oftentimes, they did not even
know that there was a treatment plan.
Of course, this is not to say that psychotherapy must be rigid and leave
out the “human factor.” Certainly, establishing rapport with the client is both
helpful and necessary, but it is a means to an end. For therapy to truly be
effective, it must progress beyond therapist–client relationship. Or, to put it
in baseball terms, getting to first base is a great first step, but if no further
progress takes place, it isn’t helpful in the long run. Too many clients state that
they go to counseling because it helps them feel good during the session, but
when they go home, nothing changes. But, it does not lead to effective change
How This Book Came Into Being xiii
between sessions. Counseling is not about being someone’s shoulder to cry

on. It is a growth process, designed for the client to eventually rely less and
less on the therapist. The book teaches documentation techniques for the full
course of therapy. It does not teach therapeutic techniques. Psychotherapy or
counseling is an entirely different set of skills related to the therapist’s beliefs,
personality, training, skill level, and what works for a specific client. Psycho-
therapy training offers a wide array of theories and techniques from which to
choose. Each have their own merits. Documentation is atheoretical. It consists
of no more than providing written evidence of the course of counseling.
CHAPTER 1
Introduction
D
ocumentation of all aspects of mental health treatment is crucial in
this age of accountability. It is the only evidence demonstrating the
need and effects of treatment. Simply stating that a client has a cer-
tain diagnosis or claiming that therapy has been helpful to the client is an
opinion but not evidence. Empirical evidence demonstrating that treatment
was necessary and effective is essential. It is possible, and even compulsory,
to document the outcomes of psychotherapy in objective, measurable terms
without mechanizing or dehumanizing the process.
The clinical skills employed in psychological treatment are unrelated to
documentation skills. It is possible to be an excellent therapist but have poor
documentation skills. And, vice versa, one can be quite adept in documenta-
tion but not very helpful as a therapist. Of course, the goal is to be proficient
in each of these realms.
It is not the purpose of this text to teach a particular mode of therapy that
is easily documented, but rather, it is to teach documentation methods and
skills that are useful for any school of thought. Therefore, the focus of this
text is not on the “how to’s” of mental health treatment, but on documenting
the necessity, goals, and effects of therapy. If the examples used in the docu-
mentation training appear to reflect a particular school of thought, it is not
intentional.
We are living in the age of both personal and professional accountability.
In addition to mental health workers, professionals such as politicians, execu-
tives, clergy, educators, and people from most walks of life have increasing
demands placed on them to demonstrate that they have practiced their pro-
fession effectively and ethically. Reading the newspaper or watching the news
on just about any given day substantiates the point of widespread ethical
concerns. Modern political debates have emphasized ethical issues as much
as political issues. An increasing number of well-known public figures have
1
2 Introduction
filled the headlines and court dockets by compromising their professional

standards. Colleges, universities, and professional schools have increased
their required ethics courses over the past several years. Most mental health
licensing boards require ongoing ethics training as part of their mandatory
continuing education. Insurance premiums for mental health professions are
often discounted when they provide evidence that they have taken ongoing
continuing education credits in ethics.
Standards of accountability in the mental health profession come from
a number of sources. State boards such as psychiatry, nursing, psychology,
social work, substance abuse, professional counselors, and marriage and fam-
ily therapy, each have specific guidelines for licensees. Accrediting agencies
such as the Commission of Accreditation for Rehabilitation Facilities (CARF)
and The Joint Commission (TJC) and third-party payers such as insurance
companies and managed care organizations maintain specific documentation
requirements to ensure accountability.
Such regulations are designed to both increase clinical effectiveness and
help curtail the rising costs of mental health services, which have skyrock-
eted over the years. Current standards of third-party payers hold that ser-
vices must be medically necessary in order to be covered for payment. Both
third-party payers and regulatory agencies impose strict requirements in
which each step of the clinical process must be clearly documented. There-
fore, providing appropriate documentation and communicating evidence of
clients’ needs for services is crucial for a clinic’s financial and professional
survival and growth. As an added bonus, many mental health professionals
have commented that after they have learned sound documentation skills,
their therapy became more on target rather than vague or unfocused.
Learning on-target documentation procedures is much more than simply
meeting professional regulations or requirements for payment of services.
Accurate recording procedures provide clear evidence of what takes place in
mental health sessions. Without accurate documentation, it is not possible to
evaluate therapeutic effectiveness because there is not a clear record of what
took place in therapy. Sloppy clinical procedures are not only unfair to the cli-
ent but can border on malpractice. During times such as a third-party audit or
a clinical review, proper documentation validates course of the therapy. When
sound documentation procedures are followed, a written record of treatment
will be available for review of (a) validation of the correct diagnosis, (b) the
medical necessity of services, (c) therapeutic effectiveness, (d) appropriate-
ness of services performed, (e) continuity of services, and (f) evaluation of
therapeutic outcomes. The result is setting a high standard for mental health
treatment.
Introduction 3
In the past, third-party payers simply paid therapists when an insurance

claim was made. Costs escalated, and thus managed care subsequently flour-
ished. Today, third-party payers no longer blindly accept billing for any psy-
chotherapy services. They require specific types of evidence demonstrating
the client’s need for services and the therapeutic effectiveness in order to pay
for the treatment. Without knowing proper documentation procedures and
how to present a case on paper, the therapist is vulnerable to appearing to be
“out of compliance” or providing “unnecessary services” even if the treat-
ment is exceptional. If it isn’t written down, it doesn’t exist.
Many therapists have claimed that they were unaware that most third-
party payers do not cover counseling that is intended solely for “personal
growth,” rather than treating psychopathology. This is not to say that coun-
seling for personal growth is not helpful, but it is typically not covered by
insurance. Thus, it is usually an out-of-pocket expense. Such counseling
likely fits under the category of the services a life coach offers. Please be
aware that insurance companies do not pay for services without adequate
documentation and a definite mental health diagnosis and related impair-
ments. It can be quite tempting to assign a diagnosis to a client, whose symp-
toms do not meet the Diagnostic and Statistical Manual of Mental Disorders
(DSM)-5 criteria for the diagnosis, in order to receive payment. Avoid this
practice at all costs. Your reputation is on the line! Always explain to each
client both the benefits and risks of having a record of mental health treat-
ment as in Box 1.1.
There are certainly other risks to clients when receiving mental health treat-
ment. Most of them are unfair to the client, who simply wants to get better. A
few of these risks include the following:
1. Being labeled as having a mental illness can lead to stereotypes by both

the client and others involved in the client’s life.
2. Poor therapy can lead to a decline in the client’s condition or a feeling
that there is no hope. I have seen too many clients who apply for dis-
ability benefits when they are convinced that they will never get better
because their previous counseling did not help, thus believing that they
will never improve.
3. Some types of counseling are inappropriate for certain clients. For exam-
ple, if for some reason a client can attend only 10 sessions (e.g., insur-
ance benefits restrictions, cost, other timing factors), and the client has a
severe mental illness that requires long-term therapy, the effects of brief
treatment could be harmful if not conducted properly. That is, there is
only time to “open the can of worms” but no resolution.
4 Introduction
Box 1.1 Realistic Example of the Benefits and Risks of Receiving

Mental Health Treatment
For the past 5 years John Doe has been under an increasing amount
of stress. He had been promoted on his job to a very stressful posi-
tion that required being on call at work 24/7. Although he was doing
well career-wise, the stress of his job took a toll on his mental health.
Gradually, it affected his marriage and attendance at work. For relief, he
spent increasingly more time at a local bar. He spent large amounts of
money unwisely, leading to significant debt. He often came home intoxi-
cated and would miss work the next day. Eventually he lost his mar-
riage, children, and his job. He felt empty inside and became severely
depressed. His parents convinced him to see a therapist and receive sub-
stance abuse treatment. In treatment, he was diagnosed with both Major
Depressive Disorder and Alcohol Use Disorder. Over time, he recovered
and was quite thankful for the treatment he received. His compliance
with professional treatment was a life changer. He was overjoyed when
he reunited with his wife and children. Without this necessary treat-
ment, he likely would have gone into deeper depression and perhaps
harder drugs. When he disclosed to potential employers that his lapses
of employment were due to mental health and chemical dependency
treatment, he soon realized that his history of both mental health treat-
ment and substance abuse affected that type of employment available to
him. He eventually found work but at a much lower level of responsi-
bility and pay. Yes, there are both benefits and risks of receiving mental
health treatment.
Although most mental health professionals are properly schooled in

conducting psychotherapy, few receive any training in documenting the
evidence of their treatment. It is not uncommon for therapists, new to the
field, to become discouraged when exposed to “the other responsibility” of
providing mental health treatment: documentation. However, when prop-
erly trained, therapists soon realize the benefits of documentation by not
only becoming more confident in meeting third-party requirements but also
becoming more aware of their client’s progresses and setbacks; they are also
more proficient at staying on task. Learning documentation procedures is a
win-win situation.
Documentation for psychotherapy is atheoretical. It does not follow a cer-
tain school of thought. It is presented as behavioral evidence, in observable and
Introduction 5
measurable terms; that have nothing to do with behavioral therapy. The clinician
may conduct psychotherapy from any effective type of treatment (e.g., cogni-
tive, behavioral, dynamic, gestalt, rational-emotive, solutions focused, etc.).
Managed care companies, along with other third-party payers and accrediting
organizations, are open to this variation, provided that there is written evi-
dence of the course of therapy, not just a narrative. The evidence is presented
in terms of objective client behaviors, not opinions or speculation. Evidence
of alleviation of specific client impairments, which are secondary to the men-
tal health symptoms, is required. They question, “What improvements in
mental health or behavioral functioning are taking place as the result of the
present therapy?” It is our job to provide this evidence by means of written
documentation throughout the treatment.
Regulatory agencies require that the same measuring stick is used to assess
the effects of therapy regardless of the treatment modality employed. The
current measurement standards in mental health require that clinical docu-
mentation be observable, measurable, and provide behavioral evidence of
therapeutic progress.
Documentation begins at the first interview. The several documentation
procedures conducted throughout therapy are interrelated. The informa-
tion collected in the initial interview is necessary for writing the treatment
plan. The treatment plan provides a guideline for the course of therapy,
which is documented in the progress notes. Progress notes are necessary for
writing a revised treatment plan. All of the information collected is needed
in writing the discharge summary and assessing outcomes as outlined in
Figure 1.1.
The documentation procedure examples provided in this text represent
a course of treatment for a client with depression. In addition, Appendix
A provides documentation examples for a client with Panic Disorder with
Agoraphobia.
Initial Diagnostic Interview

Treatment Plan
Progress Notes
Ongoing During Course Treatment Plan Revisions/Updates
of Treatment
Progress Notes
End Discharge Summary
Figure 1.1 Course of documentation

Source: Reprinted with permission of John Wiley & Sons, Inc.
6 Introduction
This text begins with teaching the rationale and examples of documentation
for each step of the therapeutic process. In addition, it provides training as to what
documentation is required for third-party payers and accreditation agencies.
HIGHLIGHTS OF CHAPTER 1
●● Accurate and specific documentation procedures are necessary for ethical,
professional, and financial reasons.
●● Third-party payers and accrediting agencies are becoming more stringent
in their required documentation procedures.
●● The intake, treatment plan, progress notes, revised treatment plan, and
discharge summary are interrelated. Although they are independent
documents, they represent a continuous process in therapy and doc-
umentation.
●● Each step in the counseling procedures has specific documentation proce-
dures, if not followed, could be detrimental to the client, therapist, and the
clinic. Likewise, all can benefit with appropriate procedures.
●● Documentation procedures are atheoretical. They do not represent a form
of treatment, but rather, they demonstrate the effects of treatment in objec-
tive, measurable terms.
QUESTIONS
1. In the medical model of documentation, the means by which a therapist
documents therapy
a. depends on the theoretical school of thought.
b. is atheoretical.
c. is not important.
d. incorporates documenting impairments rather than strengths.
2. A current requirement by most third-party payers to cover mental health
services is documenting
a. that personal growth will take place in therapy.
b. that a preexisting condition was not present.
c. proof of insurability.
d. medical necessity.
3. Client files that are audited by a third-party payer that not found to be
compliant with documentation standards
a. typically leads to loss of licensure.
b. is a minor concern to most clinicians.
c. may be subject to repaying funds back to the third-party payer.
d. is a clear violation of confidentiality.
Introduction 7
4. Typically, the evidence a third-party case manager uses to determine that

the treatment plan has been followed is found
a. in the progress notes.
b. by interviewing the client.
c. through determining the number of sessions that have been con-
ducted, to date.
d. in the initial summary report.
5. Why might counseling for the sole purpose of “personal growth” not be
covered by an insurance company?
a. It isn’t necessarily medically necessary.
b. It does not have a DSM-5 diagnosis.
c. It is too vague of a concept.
d. all of these.
Answers: 1b, 2d, 3c, 4a, 5d
CHAPTER 2
The Art and Science of Psychological

Assessment and Treatment
“There is no pretense that reason and reason alone, or that science and sci
ence alone, can prevail by themselves in any kind of human relationship,
personal or therapeutic.”
(Mann, 1973, p. 48)
M
ental health clients desire a treating professional who is knowleg
able, caring, empathic, and able to help them work through issues.
However, they do not want treatment from someone who fully
“plays it by ear” or says whatever comes into mind. A high degree of pro
fessionalism and knowledge is expected. Otherwise, why would we need
graduate training? On the other hand, clients do not desire working with a
therapist who is so scientific or technical that the human element is lost. A
combination of art and science is necessary in the delivery of mental health
services (Walborn, 1996).
Mental health professionals vary tremendously in their views of how
to accurately collect diagnostic information and conduct therapy. On one
extreme we have those who believe and practice psychology based on
their gut feelings, intuition, and their inner gift of helping others. The other
extreme consists of a close adherence to a rigid scientific medical model. If
one were to observe therapists from each of the two extremes it would seem
as if they were in different professions. Most of us are somewhere in between,
in which we rely on both the lessons of scientific research and our clinical
acumen and insight.
The clinical practices in the field of psychology follow the same pendulum
as other historical trends. Sometimes the pendulum swings toward hard sci
ence, but eventually, when it becomes too regimented; we miss the “good old
days” and gradually return to the softer sciences and less empirical methods.
9
10 The Art and Science of Psychological Assessment and Treatment
But, the further the pendulum swings, we realize that we need more empiri
cal research for our practices, and the pendulum gradually reverses.
The following two sections discuss differences between practicing therapy
as an art vs. science. Therapists are not “one or the other.” Each of us practice
somewhere between the two poles. Thus, it is likely that you adhere to some
aspects of each dimension.
THE PRACTICE OF MENTAL HEALTH AS AN ART

Many experienced and successful therapists view their clients as unique
individuals; therefore, placing them into a diagnostic category would seem
counterproductive and impersonal. They tend to reject any requirements of
placing a diagnosis on a client because it provides no more than a label that
serves little or no therapeutic purpose. They realize that the client’s concerns
are likely multifaceted. Thus, assigning a label is viewed as pointless, unhelp
ful, and potentially detrimental to their clients.
The documentation of both the assessment and therapy generally consists
of listing the client’s present feelings and noting insights gleaned by the cli
ent. This modality has been around for years and has a long history of suc
cess. In this model of a typical assessment, the therapist would not focus on
empirically validating a diagnosis to fit outside criteria but rather attempt to
soothe the client and provide hope and direction for the future. The initial
assessment session is often mixed with a number of therapeutic interventions
in which rapport develops. Focusing on the client’s immediate and long-term
needs is crucial.
The greatest strengths the therapist has are being able to focus on the here-
and- now, empathy, insight, instilling hope, and providing guidance and
emotional support. They tend to be patient with clients and allow them to
progress at their own rates. They often reject any third-party restrictions on
the modality and number of sessions allowed for treatment.
For example, if a child is referred for problems with temper tantrums, the
therapist could focus on the child’s feelings and attempt to discover why the
child has tantrums (e.g., stress, pain, home conditions, getting one’s way, etc.).
It would be important to develop a trusting relationship in order for the child
to be able to gradually trust the therapist and his/her interventions. One of
the primary goals of the therapist would be to discover the root cause of the
tantrums and help the client work through these issues. An effective therapist
would be skillful in human relationship skills to help the child become more
positively effective.
The Art and Science of Psychological Assessment and Treatment 11
THE PRACTICE OF MENTAL HEALTH AS A SCIENCE

Mental health counseling is also practiced from an empirical point of refer
ence. Therefore, scientific principles are the primary modality of assessment
and treatment. Human behavior is viewed as being subject to scientific meth
ods in which people are viewed as fairly predictable if we knew enough about
them. The causes of maladaptive behaviors can be understood if the appro
priate information is collected. All behavior and emotion have a cause and
an effect. To change behavior requires making modifications in the c lient’s
external and/or internal environment.
A common paradigm for treatment is the A-B-C model (Antecedents-
Behavior-Consequences). The antecedents are the events that take place
that trigger the behavior. The consequences are the rewards or punishments
received after the behavior takes place. The consequences might come from
others, the physical environment, or viewed subjectively by the client. A
behavior can be changed if either the antecedents and/or the consequences
are altered. A behavior remains the same or escalates if the antecedents and
consequences remain the same. For example, if a child receives attention only
when acting out he/she will continue to act out as long as attention is received.
Let us return to the child being evaluated for temper tantrums. The exam
iner, from a scientific perspective, would inquire about what takes place before
the tantrums to determine what can be altered to avoid such situations; in
addition, information would be gathered to determine the consequences for
tantrumming in order to determine what rewards or punishments (intrinsic
or extrinsic) could be increased to help prevent tantrums.
INTEGRATING THE ART AND SCIENCE OF MENTAL HEALTH

Few people practice at the extreme end of the art/science continuum
(Figure 2.1). The various schools of thought vary significantly in their view
points. For example, radical behaviorism holds to a strict scientific viewpoint
of practicing psychology, whereas humanistic and existential viewpoints fall
on the art side of clinical practice. The cognitive/behavioral school of thought
incorporates and integrates each stance. Most modern practitioners claim to
be eclectic, picking and choosing what works best for them and their clients.
Within each school of thought there is variation among practitioners.
Therapy and documentation are two very different skills to learn. A thera
pist has a choice between multitudes of theoretical frameworks, or any com
bination. Therapy can range from an intuitive to a regimented approach.
Walborn (1996) provides an excellent text, Process Variables, in which each of
The Range of Practice in Mental Health Treatment
As an Art As a Science
1 2 3 4 5 6 7 8 9 10
Humanistic/ Cognitive/ Behaviorial

Existential Behavioral
1-4 3-8 7-10
Figure 2.1 The differences and overlap in the practice of psy-

chology as an art vs. science from three theoretical points of view.
The numbers used are for example only and are not based on
specific published material.
the major therapies are compared and contrasted as to their effectiveness. The
focus of the text is that the mode of therapy is not what leads to client change.
Instead, Walborn (1996) lists four process variables, which, if they take place,
no matter what type of therapy (art vs. science), client change will take place.
These variables include (a) the therapeutic relationship, (b) cognitive insight
and change, (c) emotions in therapy, and (d) client expectations. Walborn
(1996) describes how even though the therapies might appear to be quite dif
ferent; they each treat the various components of the process variables. Thus,
it is not the therapies themselves that lead to client change, but transforma
tion takes place from the common therapeutic processes they have in com
mon. This is not to say that all therapies are the same. Although the various
therapies hold different views of what is necessary for client change, the pro
cess variables that lead to client change are common between the therapies.
DOCUMENTATION IN THE LIGHT OF ART VS. SCIENCE

Therapists differ immensely as to what should take place in a counseling ses
sion. This difference allows clients to receive treatment in a manner that best
suits their needs. Further, it allows therapists to practice the mode of therapy
according to their particular school or schools of thought. However, docu
mentation is not about psychological theories and does not follow a school
of thought. Documentation is no more than the written evidence of objective
The Art and Science of Psychological Assessment and Treatment 13
observations with supporting data. With good documentation, the client’s

progresses and course of therapy can be fairly well understood by the client,
therapist, and a third party. It can be especially helpful when a new therapist
takes over the case. Otherwise, little is known and the new therapist, for the
most part, starts over.
Documentation is used for several purposes including (a) objectively mon
itoring progresses and setbacks in treatment, (b) monitoring the effectiveness
of current interventions, (c) working collaboratively with other professionals,
and (d) audits from third parties such as those who pay for services, accredi
tation reviews, legal matters, and professional review boards. Very few thera
pists enjoy documentation; however, many therapists who have not done a
good job of documenting have, unfortunately, realized its importance when
their charts were audited.
No matter what you have chosen for the type of therapy you provide, if
does not affect what third parties require for documentation. Documentation
is atheoretical. It takes the same amount of time and effort to document if
you conduct therapy as an art or science. However, when you learn what is
expected in documentation, it can be surprising how little time it takes. Usu
ally all or most of your documentation can be completed during the session,
rather than time spent after the session. Little or no time is needed after the
session for most types of documentation.
HIGHLIGHTS OF CHAPTER 2
●● There is clearly no set or standardized means of conducting psychologi
cal services.
●● Those who view psychotherapy as an art hold values such as gut feelings,
intuition, and insight.
●● Those who view conducting psychological services as a science hold val
ues such as the scientific method, in which objective data are incorporated
into treatment.
●● Other schools of thought incorporate a combination of incorporating treat
ment as both an art and science.
●● Although the various theoretical perspectives may seem to be diverse, they
have common process variables in which their commonalities contribute to
client change.
●● No matter what therapeutic orientation a therapist follows, documentation
is atheoretical, in which current standards require an empirical format.
QUESTIONS
1. Which of the following best represents a statement from someone who
views psychotherapy as an art? “Today we worked on . . .
a. “. . . identifying why she feels rewarded by excessively washing her hands.”
b. “. . . expressing latent emotions.”
c. “. . . identifying what factors lead to outbursts at work.”
d. “. . . identifying rational behaviors.”
2. Which of the following treatment strategies would most likely be incorpo
rated by someone from a scientific perspective of psychological treatment?
a. Dream interpretation
b. Psychiatric hospitalization
c. A-B-C model
d. Expressing empathy
3. According to this text, documentation
a. is atheoretical.
b. should correspond to the theoretical model used in treatment.
c. it important, thus it requires much of the therapist’s time.
d. All of these.
4. Process variable research
a. maximizes the differences between psychological therapies.
b. suggests that there are very different processes that take place in the
various therapies.
c. suggests that documentation can be either written as an art or science.
d. integrate the similarities between psychological therapies.
5. Because the modes of psychotherapy vary tremendously, documentation
of psychotherapy
a. also differs between them significantly.
b. must clearly represent the theoretical model used in treatment.
c. is useless because it violates the client’s right to privacy.
d. None of these.
Answers: 1b, 2c, 3a, 4d, 5d
CHAPTER 3
Overview of Current Documentation

Procedures and Third-Party
Requirements
I
n the not-so-distant past, documentation consisted of little or no more than
verifying that an interview took place, making a diagnosis, perhaps mak-
ing a treatment plan, and writing rudimentary progress notes. Because
there were few specific standards, documentation was a matter of subjective
opinion. It was not given much attention in graduate schools. Although clini-
cal judgment will always be an extremely important part of understanding
client behaviors, there must be a balance of incorporating universal proce-
dures (e.g., Diagnostic and Statistical Manual of Mental Disorders [DSM]-5 cri-
teria, professional regulations, accreditation standards, third-party payer
requirements, clinic standards, etc.), when documenting services. In the past,
insurance companies that paid for mental health services listed few or no
documentation requirements to validate a diagnosis or the client’s need for
services. Clients receiving mental health services seldom knew their diagno-
sis or even if there was a written treatment plan. Now, the client’s input is an
important part in formulating, following, and revising the treatment plan.
Today, in the age of professional accountability, clinical proficiency is abso-
lutely necessary, but not sufficient, in encompassing all aspects of mental
health services. Third-party payers demand evidence that demonstrates both
the need for and effectiveness of mental health treatment. An insurance com-
pany or an accreditation agency does not interview a client to determine the
effectiveness of services. (However, at times, outcomes surveys are sent to
clients.) The professional board by which the mental health professional is
licensed will likely review a licensee’s records for a client when a complaint
is filed. They all rely on written documentation from the therapist. Therefore,
15
16 Current Documentation Procedures and Third-Party Requirements
if services are not properly documented, the most skillful therapist could
appear, on paper, to be ineffective with clients for the sole reason of inad-
equate documentation. This can lead to significant multifaceted losses (termi-
nation of services, loss of insurance contract, reimbursement to the insurance
company, suspension of licensure) to the therapist. There are cases in which
very poor documentation has been reported to professional boards, leading
to reprimands and required supervision, continuing education, and some-
times, license suspension. Documentation is a necessary part of the training
and continuing education of mental health professionals.
It can be upsetting after seeing a client for a few sessions and then being
required to request an authorization for additional services. However, with
proper training, learning appropriate documentation procedures can both
increase the quality of therapy and save writing time. Good documentation
does not equate with long reports. Brevity, coupled with specificity, can easily
be learned and is preferred by most readers.
If the therapist is not proficient in documentation procedures, it is possible
that further payment for services could be denied, even if the client highly
needs treatment. Thus, learning and following objective documentation pro-
cedures is in the best interest of both the client and the therapist. The case
manager, clinical supervisor, or auditor reviewing the case has no other infor-
mation to review other than the therapist’s written evidence. They do not sit
in on a psychotherapy session to evaluate the effects of treatment. They do
not provide a separate diagnostic interview with the client to verify the infor-
mation. Their only awareness of the client’s concerns is what you document;
that’s it!
When additional services are declined by a third-party reviewer, the rejection
is more likely due to inadequate documentation rather them refusing to allow
a needy client to receive treatment. Your documentation is the evidence for the
need for continued service. The adage, “if it isn’t written down, it doesn’t exist,”
holds especially true for clinical documentation. A client with severe mental
health problems, who receives therapy from a therapist without adequate
documentation skills, could be denied services because of the therapist’s
lack of documentation skills. Thus, poor documents can ultimately lead to
termination of insurance payment of mental health services. All too often,
therapists blame the insurance company when additional services are denied.
Services are generally denied for a reason. . .“lack of evidence.” The evidence
comes from the evidence that the therapist provides, not from the client.
When a file is audited or reviewed, the reviewers do not assume that,
because documents such as the treatment plan and progress notes are pre-
sent, all is well. The information in the chart must clearly paint a picture of
the client’s condition and necessity for treatment. The process is similar to an
Current Documentation Procedures and Third-Party Requirements 17
attorney presenting evidence in court. If there is no evidence for the case, it is

a loss. Clear evidence wins the case. This book provides examples and expla-
nations of how to document or provide clear and understandable evidence of
the need for and effects of therapy from the first to the last session.
COMPARING WHAT WE “OUGHT TO DO” TO WHAT WE WERE

“TAUGHT TO DO”
Current documentation procedures required by third parties and accrediting
agencies follow a medical model in which evidence of therapeutic effective-
ness is based on what is observable and measurable, rather than being solely
based on subjective opinions derived from intuition and insight. Undoubt-
edly, clinical intuition and insight are necessary clinical skills, but they are not
sufficient for empirical documentation. Therapists are trained from a wide
range of theoretical perspectives, dealing with mild to severe degrees of client
impairment and dysfunction. Therapists trained from a perspective empha-
sizing personal growth, increased insight, and clinical intuition are likely
to be less comfortable learning documentation procedures from a medical
model than those trained from a scientific practitioner model. Their treatment
is not the issue, for it may very well be as effective, or even more effective,
than other means of treatment depending on the client. However, the issue is
documentation of the effects of therapy, not the mode of therapy.
The criteria for the medical, or scientific practitioner, model is based on
diagnostic criteria found in the Diagnostic and Statistical Manual of Mental Dis-
orders, Fifth Edition (American Psychiatric Association [APA], 2013). This text
will provide instruction in documentation that will be especially helpful to
those whose training did not include a scientific practitioner model.
Typically, third-party payers provide a minimal number of sessions, but do
not reimburse for additional services unless they are demonstrated as being
medically necessary. Mental health professions who provide counseling that is
not considered as medically necessary, although it may be therapeutically help-
ful (e.g., personal growth counseling, relationship therapy), are likely to find the
material found in this text challenging because it explains why third-party payers
typically do not cover such services. Documentation training will help ease the
conflict of determining which services are covered by most insurance companies.
Consider the following comparative example. James wants a back mas-
sage because it helps him to relax after a long day’s work. He does not have
a medical condition but likes the feel of a back rub. He realizes that the cost
of a massage is more than he can afford, and his insurance does not pay for
a massage. He then finds out his insurance pays for physical therapy, so he
makes an appointment and requests a back massage. His thinking is that
because his insurance will pay for physical therapist, he is entitled to the ser-
vices of a physical therapist. However, his massage is not medically neces-
sary, even though it makes him feel better. Receiving services from a mental
health professional is not automatically covered because they were provided
by a professional contracted with an insurance company. If there is not a cov-
ered diagnosis and demonstrated medical necessity for services, they are not
covered by insurance. Billing for services that are not covered by an insurance
company can lead to being denied coverage, and if some sessions have taken
place, it can lead to paying back money they have paid you.
One of my first positions as a psychologist was at a large mental health
clinic to which many of the clients came for marriage counseling. The clinic
director told the therapists that the bulk of insurance companies did not pay
for this service; therefore, we were instructed to list one of the partners are
the “identified client.” We were then instructed to give this person an Axis I
diagnosis, so that there would be insurance coverage. And to top it off, we were
required to write the progress notes as if the identified client were the only one
receiving services and make no mention that the other person attended the
session. The rationale given for that was that it was for the overall good of the
family and that insurance companies “should” pay for this service. I left this
job after a very brief period because the practice was clearly an example of
insurance fraud. About one year later, the clinic was audited, the inappropriate
insurance billing was discovered, and the clinic was soon out of business.
MENTAL HEALTH GRADUATE TRAINING

Graduate school education in mental health emphasizes theory and practice
of psychotherapy. Training typically includes a wide spectrum of clinical per-
spectives, assessment procedures, interviewing, testing, diagnosis, ethics,
statistics, and research. In addition, future therapists have experiential oppor-
tunities, such as practicums and internships. The numerous skills developed
are quite time consuming, providing little time for learning much of the non-
clinical aspects of a mental health practice, including skills in documentation,
business practices, billing procedures, public relations, and obtaining con-
tracts. Training in “treatment planning” certainly involves planning a client’s
treatment but usually not how to write an observable and measurable treat-
ment plan or document client behaviors throughout the course of treatment.
Students are taught how to provide psychotherapy to clients but typically not
enough emphasis is placed on how to document, in writing, what will be con-
ducted in therapy, what was conducted in therapy, and therapeutic outcomes.
It is clearly the intention of graduate school educators that students will
learn documentation skills, but documentation training doesn’t neatly fit
into one particular graduate school course. When considering the numerous
required courses, there is usually little or no room for additional courses
in most training programs. Even if documentation procedures are not
taught specifically, it is usually assumed that students will be taught these
procedures during their practicum and/or internship experiences. Often,
though, documentation training does not take place here either, because
typically, in an internship, graduate students see clients pro bono or for
a reduced fee rather than through third-party payment; therefore, their
documentation is not subject to third-party payer regulations. In addition,
their clinical supervision typically has focused on the quality of therapy
and case conceptualization skills, which in themselves are an arduous task
to master. Historically, students’ documentation skills have not always been
scrutinized with the same rigor by their clinical supervisors as they would
be by a third-party payer. Nevertheless, documentation training in graduate
school is on the rise due to the realities in the field.
THIRD-PARTY PAYERS AND MANAGED CARE

Historically, third-party payment to mental health providers is a relatively
recent phenomenon. Lobbying on the part of mental health professionals and
employers has led to the inclusion of mental health care in many health care
insurance packages. However, more recently, mental health coverage has been
increasingly restricted. There was a time when, if a client’s insurance policy
covered mental health services, he or she could receive seemingly unlimited
services from their provider of choice. Mental health providers simply filled
out insurance forms and soon received payment. Not surprisingly, some peo-
ple with little or no functional impairments spent several years in counseling,
with no review of therapeutic necessity or effectiveness. As a result, the cost
of mental health benefits skyrocketed, and third-party payers had no choice
but to find means to lower mental health costs to remain competitive, stay in
business, and also fund covered services. Managed care, with its focus on cost
containment, was the end result.
More than any other change agent, managed care has transformed the
scope and nature of mental health services. Before managed care existed, it
was often easier to receive insurance benefits for nonmedically necessary
counseling services. Costs increased dramatically over time due to generous
benefits. Thus, counseling services such as for personal growth, relationship
therapy, and psychoeducational services are now not generally covered by
insurance. This author is not negating the positive and life-changing effects of
these types of counseling but is simply noting current third-party criteria that
as a rule, do not cover nonessential counseling. Medical necessity is not an

issue when services are not paid for by a third party. The DSM-5 (2013) states,
The diagnosis of a mental disorder should have clinical utility: It should help
clinicians to determine prognosis, treatment plans, and potential treatment
outcomes for their patients. However, the diagnosis of a mental disorder is not
equivalent to a need for treatment. (p. 20)
That is, clinical documentation must clearly demonstrate that treatment is

necessary for the client to function adequately.
Managed care, in many cases, has reduced the types of services available
to those only viewed as medically necessary, and it requires that the
therapist must, on an ongoing basis, demonstrate that services are medically
necessary. When there is not sufficient evidence of a client’s impairments
being reduced as a result of mental health treatment, third-party
payment for services are meant to be discontinued. Without appropriate
documentation, there is no means to gauge the effects or medical necessity
of treatment. This can lead to a number of potential issues that could be
faced by the client, therapist, and the clinic (e.g., having to bill the client
for services not covered, facing potential malpractice issues, and possibly
harming the clinic’s reputation).
Although practitioners from different treatment modalities might disagree
about which therapeutic methods lead to effective change, documentation
is meant to be theoretically neutral. Good documentation skills enable
therapists from any school of thought to demonstrate the need for services
and demonstrate therapeutic effectiveness. Therapists from all schools of
thought can learn to document therapeutic progress and not worry about
their insurance claims being rejected due to insufficient documentation.
Documentation involves clearly demonstrating, in writing, that effective
changes or efforts for change are taking place in the clients functioning in the
realm of the diagnosis. It is not an evaluation of the therapeutic techniques
employed by the therapist unless the techniques used are contraindicated.
Managed care’s intent is to provide affordable, medically necessary ser-
vices to clients and reduce services that are unnecessary. The quality of docu-
mentation is the sole means of how a third-party, who never meets the client,
determines whether services are medically necessary and appropriate. Thera-
pists who learn such documentation procedures typically have no problem
receiving payment for services and receiving authorization for continued
services. Poor documentation can potentially become both an ethical and a
financial nightmare to a therapist. See the opening story about this author’s
experience several years ago.
MEDICAL NECESSITY
The concept of medical necessity has dramatically influenced current third-
party reimbursement procedures for mental health services. Mental health
services are considered medically necessary when the client is significantly
impaired in areas such as social, occupational, educational, behavioral, emo-
tional, or other types of functioning. Plus, without mental health services, the
client is not likely to improve or return to premorbid or adequate functioning.
Thus, mental health services are medically necessary in such cases.
Prior to adopting the medical necessity model, third-party payers paid for
services when qualified clinicians diagnosed clients with a mental health disorder.
This is still part of the process, but receiving a diagnosis alone is not sufficient to
guarantee payment for services. A person who endorses a number of symptoms
of, for example, Major Depressive Disorder, might be functioning adequately
socially, occupationally, and in other areas. Simply experiencing some mental
health symptoms may not fit the third party’s criteria for coverage of mental
health services. That is, services might be helpful but may not be necessary. For
example, if someone is going to work every day, spending time with friends,
and keeping up with typical daily activities but feels sad, it might not meet the
medical necessity criteria of a third-party payer. Thus, if the therapist does not
document impairments, there is no evidence of medical necessity for services,
and payment for services could possibly be denied. This does not contradict the
DSM-5’s similar designation that symptoms, by themselves, are not sufficient to
assign a diagnosis. There must be accompanying impairments described.
One could say that there are two types of counseling services: those which
are medically necessary (which would qualify for insurance payment), and
those which are not necessary (not qualify for insurance payment); both
of which are helpful to the client. One fits the criteria for most third-party
payers, whereas the other does not.
Criteria for diagnosing a mental health diagnosis have also been in tran-
sition. The typical procedure several years ago for making a diagnosis was
simple endorsement of mental health symptoms that defined a diagnosis.
For example, if a client endorses having a number of symptoms of depres-
sion such as weight loss, low appetite, sadness, decreased concentration, and
decreased sleep, it is likely that a diagnosis would be given in the past solely
based on symptoms. However, simply endorsing symptoms is not enough
because it does not imply the degree (i.e., mild to severe) of the symptoms
or their effect on the client’s functioning. Current diagnosis procedures must
validate both the existence and degree of symptoms and demonstrate that
there are resultant impairments as a result of the mental health disorder.
The degree to which symptoms affect the client’s behavior and functioning
is much more significant than acknowledging that symptoms exist. To qualify
for treatment reimbursement, symptoms must be documented so that a third-

party review can understand their functional impact on the client. Thus,
clinicians must also learn to document the onset, frequency, antecedents,
intensity, and duration of symptoms as well as the resulting functional
impairments, when documenting.
MENTAL HEALTH CRITERIA

Some third-party payers provide vague criteria for reimbursement for men-
tal health services, supplying few, if any, examples of what is expected in
documentation. There are no clear statuary requirements, other than from
state-funded Medicaid. Medicaid provider manuals range in specificity from
state to state. Some states that license mental health facilities periodically
audit charts to monitor the quality of services. State licensure boards typically
publish some guidelines for documentation but not at the specificity level of
managed care or accrediting agencies.
Few widely accepted standards of documentation exist. Even the stand-
ards from accreditation agencies (e.g., Commission of Accreditation for Reha-
bilitation Facilities [CARF], The Joint Commission), are quite extensive and
exhaustive, there is room for subjective interpretation. This writer recalls a
previous accreditation visit in which the auditors sent from the accreditation
agency appeared to have difficulty agreeing on rating various charts.
Third-party payers have different specific requirements for reimbursement
of services from state to state and company to company, but many of the
guidelines are fairly consistent, such as:
1. Services must be medically or therapeutically necessary.

2. Services must be directed toward a diagnosable mental illness or disorder.
3. Services must be consistent with the diagnosis and degree of impairment.
4. There must be documentation of reasonable progress consistent with the
treatment of the disorder.
5. The treatment plan must include specific discharge criteria written in
behavioral terms.
6. The type of treatment must be consistent with what is accepted in the
field. Often, “experimental therapies” and therapies that are contraindi-
cated are not acceptable.
7. Services must be specifically directed toward the diagnosis.
8. To receive continued services, there must be documented evidence of
continued impairment.
9. The progress notes must clearly reflect the treatment plan goals and
objectives.
Comparison to Documentation in Other Fields

When someone has an auto accident and has insurance coverage to pay
for the car being repaired, the insurance company will not accept a bill
from the repair shop until evidence of what repairs took place is pro-
vided. Their methods of documentation may include photographs of
the damage and a detailed list of services that are concordant with
acceptable standards. Payment is not necessarily based on the bill but
what the insurance company allows for each aspect of the repair.
Likewise, when a dentist performs certain services, X-rays must first be
sent to the insurance company as evidence of the need for services. In the
delivery of mental health services, it is not possible to take photographs
or X-rays of the problems; therefore, we provide written documentation
that follows the same general principles.
Without such criteria, there is not clear means of documenting that the ser-
vices being rendered are needed. Although third-party payers’ specific regu-
lations regarding forms, frequency of reports, and so forth may differ in some
areas, the overall information requested is remarkably similar.
CRITERIA FOR CLINICAL SIGNIFICANCE

The DSM-5 (APA, 2013) states:
A mental health disorder is a syndrome characterized by significant disturbance

in an individual’s cognition, emotion regulations, or behavior that reflects a
dysfunction in the psychological, biological, or developmental processes
underlying mental functioning. Mental disorders are usually associated with
significant distress or disability in social, occupational, or other important
activities. (p. 20)
THE O-F-A-I-D (OF AID) PROCEDURE

The acronym O-F-A-I-D is a helpful procedure that may be used through-
out the course of therapy to help provide measurable evidence of client
progresses. The information, additionally, helps confirm a diagnosis and
demonstrate outcomes of treatment. The O-F-A-I-D acronym stands for
Onset
Frequency
Antecedents
Intensity
Duration
Term Description
Onset When symptoms and impairments began
Frequency How often or frequently symptoms and
impairments occur
Antecedents Events or stressors leading to onset/exacerbation
of symptoms
Intensity Severity of symptoms (e.g., mild, moderate, severe, or
scale (e.g., 1–100)
Duration How long (seconds, minutes, hours, etc.) symptoms last
Example of Documentation with O-F-A-I-D Procedure

Client with Depression Halle P. states that she has been depressed for the past
year (Onset) since her child was removed from the home by the Department
of Social Services (Antecedents). She states that she feels depressed over 70%
of the time (Frequency). She has become increasingly more depressed when
she sees little children, which remind her of her child who is currently placed
in foster care (Antecedents). When asked about the level of her depression,
she states that, on a 1–100 scale, it is usually around 75–80, which she further
describes as “moderate” (Intensity). She further adds that she has bouts of
depression, during which she isolates herself in her room up to 10 hours per
day (Duration).
Client with Panic Attacks Mya W. began having panic attacks when she lost
her job (Antecedents) 6 months ago (Onset). Currently, she has an average of
three panic attacks per day (Frequency), which last an average of 5–30 min-
utes (Duration). Panic attacks typically take place when she leaves the house,
when the phone rings, or when someone comes to her door (Antecedents).
She describes the effects as severe, rating them as a 95 on a scale of 1–100
(Intensity).
Use of the O-F-A-I-D Procedure in Validating a Diagnosis

Although validating a diagnosis is discussed in more detail in Chapter 7, a
brief explanation of validating a diagnosis with the O-F-A-I-D procedure is
given here. The DSM-5 lists specific requirements that must be met in order
to make a diagnosis. The specific types of requirements vary by diagnosis;
however, the O-F-A-I-D procedure is helpful in validating or providing sup-
portive evidence that the diagnosis given to a client matches specific DSM-5
criteria. (See Table 3.1)
The DSM-5 notes that it is possible for a person to experience symptoms
of a disorder but not be diagnosed as such because the severity of the symp-
toms is not enough to validate that impairments are prevalent. Insufficient
documentation can make clients appear, on paper, to be less afflicted than
they actually are. If medical necessity is not found to be evident due to insuf-
ficient or inadequate documentation, reimbursement might be denied. Both
symptoms and impairments must be validated to properly assign a diagno-
sis. Simply diagnosing a client by the sole means of a symptom checklist is
insufficient evidence. The resultant impairments must accompany the listed
symptoms. The following examples highlight incidents where medical neces-
sity is not adequately documented:
Depression
●● Poorly Documented Symptoms: “The client is depressed, withdrawn, suf-
fers from lack of sleep and fatigue, feels anxious, and has feelings of
confusion.”
●● Specific Problems in the Documentation: This statement does not provide
adequate documentation for a diagnosis because it lists only symptoms.
The evidence presented does not provide evidence of impairments. It is
possible that the client is functioning adequately because the severity of
Table 3.1
Example of Use of O-F-A-I-D Procedure in Validating a Diagnosis of
Major Depressive Disorder
DSM-5 criteria for diagnosis Example of validation
Depressive symptoms or lack of “Client has been depressed for the past 8
pleasure for at least 2 weeks months.” (onset)
Depressed most of the time “Client states that she is depressed most of the day at
least 5 or more days per week.” (duration and frequency)
No DSM-5 requirement for antecedents for
this diagnosis
Qualifiers of mild, moderate, “Level of depression is severe, due to significant
severe, and other descriptors impairments socially and occupationally.” (intensity)
Note: Not every facet of O-F-A-I-D is required in this case.

symptoms is minimal. According to this documentation the client might

need services, but it is uncertain.
A normal life stressor could lead to these symptoms. People, at times,

experience some degree of these symptoms and are not considered
psychopathological. For example, if a person fails an important college
exam, it is possible that the person, for a few days, could feel down,
avoid others, lose some sleep, feel hopeless, tired. These symptoms, on
paper, might look like a depressive disorder, but when considering other
factors such as duration and intensity of symptoms, they appear to be a
normal reaction to a normal life stressor. In this case the symptoms are
expected, given the situation. If the documentation does not list specific
impairments that are the result of the noted mental health disorder, there
is insufficient evidence to validate the diagnosis.
This writer strongly cautions overdiagnosing clients in which the symp-
toms listed are based on a checklist or self-report. Such “tests” typically do
not include allowances for situational factors, time periods, degree of sever-
ity, and resulting impairments. I have seen literally hundreds of psychologi-
cal evaluation reports in which the diagnosis was based on such measures.
This “quick and easy” means of assessment is clearly in no one’s best interest.
Such measures have their place in an initial screening but not as the basis of
a diagnosis.
●● Properly Documented Example: “The client meets criteria for Major

Depression as evidenced by feeling depressed most of the time for the past
2 months, withdrawing from almost all people, daily suicidal ideations,
sleeping less than 3 hours per night, physical and mental fatigue, and
increased worrying. There is resulting educational, social, and physical
impairment in that he has not attended college classes in over one month
and usually stays in his room by himself, avoiding friends and family, and
he has lost over 10 pounds in the past 2 weeks due to loss of appetite.”
Panic Attacks
●● Poorly Documented Example: “The client has panic attacks.”
Specific Problems in the Documentation: This statement also does not
provide enough information to warrant a diagnosis of a mental disor-
der. The label “panic attacks” could be explained using the O-F-A-I-D
procedure to provide a clearer picture of the history and level of symp-
tomology. Most people have had at least one panic attack in their lives,
but it does not constitute a panic disorder. Others have frequent, debili-
tating panic attacks causing significant dysfunction that interferes with
a wide array of daily activities. The main problem with this statement is
that it could apply to someone with panic attacks of any degree, whether
very mild or severe. The description is missing evidence of the DSM-5
criteria for a panic disorder and the resulting impairments.
●● Properly Documented Example: “The client experiences panic disorder
without agoraphobia. Symptoms last at least 10–20 minutes and have
occurred at least twice per day for the past year. DSM-5 symptoms
endorsed include palpitations, hot flashes, sweating, chest pains, dizzi-
ness, trembling, and fleeing the situation. Panic attacks take place when-
ever he is in any stressful situation and cannot cope. During the past 3
months, panic attacks have increased in duration from an average of
2 per week to an average of 1 per day. Previously panic attacks lasted
no more than 5–10 minutes. Current impairments include avoiding any
new or stressful situations and leaving work early approximately three
to four times per week. He has gone to the emergency room three times
in the past month, believing that he was going to die.”
Adjustment Disorder Example 1

●● Poorly Documented Example: “The client is having trouble coping with an
Adjustment Disorder due to a recent divorce and death of a loved one.”
●● Specific Problems in the Documentation: This statement does not justify the
need for treatment. These are normal life stressors or events that many
people experience. There is no evidence of abnormal impairments or a
need for mental health services. It is expected that a person would have
difficulty coping with a recent divorce and the death of a loved one, but
there is no documented evidence of a mental health disorder. Although
mental health counseling might be needed, there is no supporting evi-
dence of the necessity this level of documentation.
●● Properly Documented Example: “The client is experiencing an Adjustment
Disorder with depressed mood as evidenced by increased depression,
withdrawal, and difficulties coping. Symptoms have occurred since the
onset of two major stressors in the past 3 months including the death of
his mother and his divorce. Affective impairment is noted as evidenced
by feeling dysphoric most of the time and having difficulties feeling
motivated to work, shop, or resume usual activities. Concerns include
crying several times per day, missing work at least twice per week, and
avoiding all social supports.”
Adjustment Disorder Example 2

●● Poorly Documented Example: “The client goes to work only 1 or 2 days per
week, has no friends, and has not phoned any family members for more
than 2 months.”
●● Specific Problems in the Documentation: In this case, functional impair-
ments might exist, but no mental disorder is documented. The impair-
ment must be the result of a mental disorder to demonstrate medical
necessity for receiving mental health treatment. Otherwise, services
other than mental health may be needed. The documentation also does
not indicate whether these behaviors represent a significant change in
functioning or if the client simply chooses to work temporary jobs spo-
radically work and prefers to be alone. One cannot assume psychopa-
thology, based on a lifestyle that is not mainstream.
●● Properly Documented Example: “The client has felt depressed for the past
3 weeks as evidenced by suicidal ideations, feeling hopeless and worth-
less, and excessive eating. There is resulting affective, cognitive, edu-
cational, and physical impairment as evidenced by constant fatigue,
missing school 50% of the time from lack of sleep (average 3 hours/
night), decreased concentration (unable to comprehend after reading
more than 3 to 4 minutes at a time), weight gain of 12 pounds in past 3
weeks, and increased negative self-statements noted by others.”
Figure 3.1 provides a helpful format to use when documenting a client’s

symptoms and resulting impairments or dysfunctions. Documentation pro-
cedures that state only whether symptoms exist can be compared to stating
that an automobile tire is low on air. Automobile tires at some time are low
on air. This may be because the automobile has hit a bump, because of cold
weather, or even as a result of normal wear. Just because a tire is low on air
The client has been experiencing (problem area) for the past (time span)
as evidenced by (list of symptoms that are concordant with DSM-IV) resulting
in (specific areas of impairment) impairment(s) as evidenced by (specific
examples of functional impairments) .
Figure 3.1 Suggested format for documenting client symptoms and functional
impairments
does not always mean the driver cannot drive the car. The severity of the
problem depends, in part, on how low tire is on air. A tire that is designed to
have 32 psi (pounds per square inch) of air pressure will likely work fine if
the pressure is anywhere from 25–40 psi. But, if the air pressure is, for exam-
ple 2 psi, it is not drivable, and needs services before the car can be driven
again. Other descriptors, such as how long there has been trouble with the
tire losing air, how often it must be filled up, and the condition of the tire will
help you make a more informed decision about whether to continue driving
the car or to take it in for service. Likewise, listing vague mental health symp-
toms alone does not provide enough specific information to make a diagnosis
or plan treatment.
Figure 3.2 illustrates the difference between simply listing a client’s symp-
toms and documenting the impacts of those symptoms by adding qualifi-
ers to demarcate additional dimensions of impairment. Profile 1 represents
two clients appearing to suffer from the same problem. Notice the difference,
however, when further descriptors are added in Profile 2.
Adding the descriptors of the O-F-A-I-D procedure provides evidence
that Client B is more severely impaired than Client A. Documentation pro-
cedures that address only symptomology miss this important distinction.
For this reason, it is difficult to make a clear diagnosis when only symp-
toms are described. Likewise, it is difficult to convince third-party pay-
ers that a diagnosis (or treatment) is warranted when only symptoms are
documented.
In addition, when documentation of specific functional or behavioral
impairment is lacking, there is meager evidence to use in determining the
type and number of services most appropriate for the client. The DSM-5
(APA, 2013) states, “Therefore, a generic diagnostic criterion requiring dis-
tress or disability has been used to establish disorder thresholds, usually
worded, “the distress causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning” (p. 21).
Appropriate documentation for diagnosis, treatment planning, and reim-
bursement requires specifying the degree to which symptoms are impairing
various areas of the client’s functioning. Current standards in documentation
incorporate the level of functional impairment as the measurement stand-
ard of the effects of mental illness symptoms. Incorporating impairments
and dysfunctions presents a sharper picture of a client’s mental status. Also,
decisions regarding the medical necessity of treatment are more clearly com-
municated, and treatment planning may be written and understood more
clearly when examples of the client’s level of functioning are included in
the report.
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The Psychotherapy Documentation Primer 4Th Edition Donald E Wiger Full Chapter

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the PSYCHOTHERAPY

DOCUMENTATION PRIMER 4th Edition

Appendix A Putting it all Together: Documented

that there is documented evidence that psychotherapy was necessary. They

between sessions. Counseling is not about being someone’s shoulder to cry

filled the headlines and court dockets by compromising their professional

In the past, third-party payers simply paid therapists when an insurance

1. Being labeled as having a mental illness can lead to stereotypes by both

Box 1.1 Realistic Example of the Benefits and Risks of Receiving

Although most mental health professionals are properly schooled in

Initial Diagnostic Interview

Figure 1.1 Course of documentation

4. Typically, the evidence a third-party case manager uses to determine that

The Art and Science of Psychological

THE PRACTICE OF MENTAL HEALTH AS AN ART

THE PRACTICE OF MENTAL HEALTH AS A SCIENCE

INTEGRATING THE ART AND SCIENCE OF MENTAL HEALTH

The Range of Practice in Mental Health Treatment

Humanistic/ Cognitive/ Behaviorial

1-4 3-8 7-10

Figure 2.1 The differences and overlap in the practice of psy-

DOCUMENTATION IN THE LIGHT OF ART VS. SCIENCE

observations with supporting data. With good documentation, the client’s

Overview of Current Documentation

attorney presenting evidence in court. If there is no evidence for the case, it is

COMPARING WHAT WE “OUGHT TO DO” TO WHAT WE WERE

MENTAL HEALTH GRADUATE TRAINING

THIRD-PARTY PAYERS AND MANAGED CARE

as a rule, do not cover nonessential counseling. Medical necessity is not an

That is, clinical documentation must clearly demonstrate that treatment is

for treatment reimbursement, symptoms must be documented so that a third-

MENTAL HEALTH CRITERIA

1. Services must be medically or therapeutically necessary.

Comparison to Documentation in Other Fields

CRITERIA FOR CLINICAL SIGNIFICANCE

A mental health disorder is a syndrome characterized by significant disturbance

THE O-F-A-I-D (OF AID) PROCEDURE

Example of Documentation with O-F-A-I-D Procedure

Use of the O-F-A-I-D Procedure in Validating a Diagnosis

DSM-5 criteria for diagnosis Example of validation

Note: Not every facet of O-F-A-I-D is required in this case.

symptoms is minimal. According to this documentation the client might

A normal life stressor could lead to these symptoms. People, at times,

●● Properly Documented Example: “The client meets criteria for Major

Adjustment Disorder Example 1

Adjustment Disorder Example 2

Figure 3.1 provides a helpful format to use when documenting a client’s

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