Running head: TREATMENT PLAN REASSESSMENT
Treatment Plan Reassessment
Carl B. Fletcher
Grand Canyon University: PCN-610
April 3, 2019
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TREATMENT PLAN REASSESSMENT
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Treatment Plan Reassessment
A reassessment of the initial treatment plan is warranted due to the follow-up and
worsening of the presenting symptoms identified in the initial plan. This reassessment, therefore,
is based on the need to assess the effectiveness of the initial treatment plan and revisions to it to
ensure a better approach to the presenting problems of the client. The changes are due to
ineffective initial treatment planning or execution and hence the need for changes in the plan for
more effective approaches to the client. The change in Eliza’s behavior was the continued
alcohol consumption which escalated to the point where she was found passed out due to alcohol
consumption.
The changes in Eliza occurred due to gaps in treatment planning and implementation. The
initial treatment plan was designed for anxiety reduction, maintaining abstinence from alcohol,
and increasing coping skills. Specifically, the treatment for abstinence was based on the need to
identify negative consequences of alcohol and hence maintain abstinence through weekly group
therapies. From the changes that have been witnessed since the institution of this program, it
seems that the approach did not work to highlight the negative consequences as planned. The
changes occurred probably due to the lack of commitment to identifying the negative
consequences and learning from them.
The initial treatment plan and its components aimed at alcohol abstinence may have been
compromised by the level of treatment being inadequate for Eliza’s diagnosis. In the initial
treatment, it was identified that Eliza’s alcohol drinking was not a major problem and hence the
treatment approach used was to prevent the client from getting into trouble with the
administration for bringing alcohol to the dormitory. However, a reassessment of this treatment
plan shows that her level of dependence on alcohol may have not been clearly identified. The
TREATMENT PLAN REASSESSMENT
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current state shows that the dependence is higher than earlier predicted and hence a more
thorough and focused treatment option is required.
The treatment plan will be changed from the current identification of negative
consequences to commitment to recovery program. According to Batra et al. (2016), relapses in
alcohol abstinence mainly occur due to the lack of further treatment after initial detoxification.
Therefore, when using pharmacotherapy as the basis for changing the treatment plan for Eliza,
there is the need to initiate a full recovery process which will effectively condition her for life
without drugs. This will effectively contribute towards her health. This adjustment will further be
accompanied by a reassessment of the other treatment options including anxiety reduction and
coping skills. On a secondary level and after the initiation of the recovery program. Eliza will be
assessed for effectiveness of the complementing treatment options. The reason for this
adjustment in the treatment plan is to adopt a more effective approach to treating Eliza. This is
ethical in that it enhances the beneficence of care as one of the principles followed in practice.
Additionally, the reassessment allows the counselor to identify their areas of competence and
refer the client to the necessary resources for effective treatment.
Moreover, the changes to the treatment plan mean one major change will be implemented
in the client’s schedule; the move from group therapy to a more committed recovery group based
on pharmacotherapy and alcohol recovery treatment. The change identified has been linked to
the need to boost the efforts of the treatment plan to implement more thorough and focused
treatment of the client when it comes to alcohol abstinence. This will be through
pharmacotherapy and recovery therapy commitment. This change means that the resources used
with the client will also change. The care accorded to her will also be changed and revved up for
better treatment. This will also require an assessment for referral requirements. According to (),
TREATMENT PLAN REASSESSMENT
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the main resource that is checked in making a referral is the human resource and their capability
to competently deliver the required service. Therefore, the counselor’s qualifications and
experiences running a full recovery program should be assessed. Secondly, the equipment to
carry out the treatment should be checked. These include the relevant facilities for the recovery
program and the relevant programs for the same.
When making the referral, a delicate task is communicating to the client need for referral
and how the referral process will work to their advantage. This process is critical because it has
to show that the counselor cares for the client and also gain approval from the client.
Furthermore, it should protect the client from falling through the cracks and falling out of
treatment. Having cultivated a relationship of trust with the client, the counselor has to establish
continuity of care and show collaboration with referral parties so as to not only maintain the
client’s confidence but also ensure effectiveness in maintaining treatment (Levy and Williams,
2016). The best approach is maintaining the confidentiality of the client and explaining to them
why referral is the best approach. This would be through showing them that referral would
improve the treatment and offer a more effective approach. The counselor should thus approach
the client and explain the need for referral while showing that they will remain in contact and the
counselor will follow closely on her treatment.
From the reassessment of the initial treatment plan developed for Eliza, the referral
suggested will be mainly to a drug recovery practitioner. This referral is mainly due to the
incompetence of the counselor in delivering that focused treatment to the client. This referral will
be completed upon further review of the treatment plan for anxiety reduction and coping skills.
Furthermore, various instruments may be used for assessing the patient and one such instrument
is the Rapid Alcohol Problems Screen (Raps). This instrument is useful in assessing alcohol use
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disorders meeting the criteria for DSM-5 (Cherpitel and Ye, 2015). Using the assessment tool,
the level of alcohol dependence and use disorder can be estimated for proper referral and
treatment.
The initial treatment plan for Eliza failed due to inadequate treatment approach hence the
need for a more rigorous treatment for alcohol dependence. The client’s alcohol use has
escalated despite having been placed in therapy to identify the adverse effects of alcohol. This
warrants the implementation of a recovery therapy for the client. Referral to professional drug
recovery expert will be required to ensure that the client’s needs are effectively met in the
treatment. Maintaining contact with and close monitoring of the client’s progress throughout the
referral will be crucial for treatment completion.
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References
Batra, A., Müller, C. A., Mann, K., & Heinz, A. (2016). Alcohol Dependence and Harmful Use
of Alcohol: Diagnosis and Treatment Options. Deutsches Ärzteblatt
International, 113(17), 301.
Cherpitel, C. J., & Ye, Y. (2015). Performance of the RAPS4/RAPS4-QF for DSM-5 compared
to DSM-IV alcohol use disorders in the general population: Data from the 2000–2010
National Alcohol Surveys. Drug and Alcohol Dependence, 151, 258-261.
Levy, S. J., & Williams, J. F. (2016). Substance use screening, brief intervention, and referral to
treatment. Pediatrics, 138(1), e20161211.
Treatment Plan
Based on the information collected in Week 4, complete the following treatment plan for your client
Eliza. Be sure to include a description of the problem, goals, objectives, and interventions. Remember
to incorporate the client's strengths and support system in the treatment plan.
Client: _Eliza D__________________________ Date: __4/3/2019________ Age:__18___ DOB:
__________________
DSM Diagnosis
ICD Diagnosis
Generalized Anxiety Disorder
F41.1
Goals / Objectives:
□ Mood Stabilization
□ Anxiety Reduction
□ Reduce Obsessive
Compulsive Behaviors
Interventions:
Frequency:
□ Psychotropic Medication Referral
& Consultation □ Journaling
□ Weekly □ Bi Weekly □
Monthly
□ Cognitive Behavior Therapy
□ Skill Training
□ other:
____________________
□ Emotion Recognition – Regulation
Techniques
□ Group □ Individual □
Family
□ Psychotropic Medication Referral
& Consultation □ Journaling
□ Weekly □ Bi Weekly □
Monthly
□ Cognitive Behavior Therapy
□ Skill Training
□ other:
____________________
□ Relaxation Techniques
□ Group □ Individual □
Family
□ Psychotropic Medication Referral
& Consultation □ Journaling
□ Weekly □ Bi Weekly □
Monthly
□ Cognitive Behavior Therapy
□ Skill Training
□ other:
____________________
□ Group □ Individual □
Family
© 2017. Grand Canyon University. All Rights Reserved.
□ Decrease Sensitivity to
Trauma Experiences
□ Verbalize Memories Triggers
&Emotion
□ Weekly □ Bi Weekly □
Monthly
□ Desensitize Trauma Triggers and
Memories
□ other:
____________________
□ Utilize Healing Model/Support
(Mending the Soul)
□ Group □ Individual □
Family
□ Establish and Maintain Eating □ Overcome Denial □ Identify
Disorder Recovery
Negative Consequences
□ Maintain Abstinence from
substances (Alcohol/Drugs)
□ Weekly □ Bi Weekly □
Monthly
□ Menu Planning □ Nutrition
Counseling □ Body Image Work
□ other:
____________________
□ Healthy Exercise □ Trigger Mngmt
Recovery Plan □ CBT
□ Group □ Individual □
Family
□ Substance Use Assessment □
Stepwork □ Overcome Denial □
Identify Negative Consequences □
Commitment to Recovery Program □
Attend Meetings □ Obtain Sponsor
□ Weekly □ Bi Weekly □
Monthly
□ other:
____________________
□ Group □ Individual □
Family
□ Increase Coping Skills
□ DBT Skills Training □ Problem
Solving Techniques
□ Weekly □ Bi Weekly □
Monthly
□ Emotion Recognition & Regulation
□ Communication Skills
□ other:
____________________
□ Group □ Individual □
Family
□ Stabilize, Adjustment to New
Life Circumstances
□ Alleviate Distress
Behavior Therapy
□ Cognitive
□ Weekly □ Bi Weekly □
Monthly
□ Stress Management □ Skills
Training
□ other:
____________________
□ Improve Daily Functioning □
Develop Healthy Support
□ Group □ Individual □
Family
© 2017. Grand Canyon University. All Rights Reserved.
□ Decrease/Eliminate Self
Harmful Behaviors
□ Cognitive Behavior Therapy □
Skills Training
□ Weekly □ Bi Weekly □
Monthly
□ Develop and Utilize Support
System
□ other:
____________________
□ Group □ Individual □
Family
□ Improve Relationships
□ Communication Skills □ Active
Listening □ Family Therapy
□ Assertiveness □ Setting Healthy
Boundaries
□ Weekly □ Bi Weekly □
Monthly
□ other:
____________________
□ Group □ Individual □
Family
□ Improve Self Worth
□ Affirmation Work □ Positive Self
Talk □ Skills Training
□ Weekly □ Bi Weekly □
Monthly
□ Confidence Building Tasks
□ other:
____________________
□ Group □ Individual □
Family
□ Grief Reduction and Healing
from Loss
□ Develop Anger Management
Skills
□ Psychoeducation on Grief Process/
Stages
□ Weekly □ Bi Weekly □
Monthly
□ Process Feeling □ Emotion
Regulation Techniques
□ other:
____________________
□ Reading/Writing Assignments □
Develop/Utilize Support
□ Group □ Individual □
Family
□ Decrease Anger Outbursts □
Emotion Regulation Techniques □
Cognitive Behavior Therapy
□ Weekly □ Bi Weekly □
Monthly
□ Increase Awareness/Self Control
□ other:
____________________
□ Group □ Individual □
Family
© 2017. Grand Canyon University. All Rights Reserved.
Topic 8 Discharge Summary Template
Directions: Complete the Discharge Summary form by addressing the fields below.
Client Name: [Enter the client's name here]
Date of Birth: [MM/DD/YYYY]
Date of Admission: [MM/DD/YYYY]
Date of Discharge: [MM/DD/YYYY]
Presenting Problem Upon Admission:
[State the client's presenting problem upon admission here.]
Current Medication:
[List the client's current medications here.]
Reason for Discharge:
[State the client's reason for discharge here.]
Resources and Referrals:
[List the client's resources and referrals here.]
© 2017. Grand Canyon University. All Rights Reserved.
Projected Prognosis:
[State the client's projected prognosis here.]
Eliza D 00/00/00
Client Signature & Date
Case Manager Signature & Date
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