Running head: ASSESSMENT AND INITIAL TREATMENT PLANNING
Assessment and Initial Treatment Planning
Donald R. Owen
Grand Canyon University PCN-610
2/4/2020
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ASSESSMENT AND INITIAL TREATMENT PLANNING
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Assessment and Initial Treatment Planning
Part one: Intake
The intake report provides information on a female student aged 18, studying at City
University. Eliza stays in the dormitory within the school premises. The information will be used
to survey an initial treatment plan for her as she has been reported to have low self-esteem,
anxiety, and stress. The intake report provides basic information as to the feelings she has
reported and needs to be addressed by a professional. For this reason, Eliza has had sessions with
the school counselor, who aims to refer her appropriately. This paper lays emphasis on the
intake, biopsychosocial assessment, treatment planning, and methods of referral for the client.
The intake report is essential for the psychosocial examiner to establish how the environment
within which the patient resides in affects her psychological wellness. Environmental factors
have been proven to influence a person's character significantly. The main aspects of the report
for intake that may be used to explain the stress, anxiety, and low self-esteem in Eliza include
her home environment, which is her parents and her school environment, which includes her
fellow students.
The Level 01 Cross-Cutting Measure (CCM-1) is one of the measures for assessing
patients that got developed for the purpose of administration during the initial stage of
interviewing patients and to also establish a plan for treatment for the patient as well as to
monitor the treatment progress for the patient (Bravo et al., 2018). Monitoring the progress of the
treatment for the patient makes it possible to establish whether the treatment should be continued
or collapsed. If the treatment does not improve the patient’s condition, it is essential that another
treatment plan gets commenced immediately to ensure that the patient doesn’t waste time
focusing on a treatment that is not beneficial to them. Cross-Cutting Measures focus on
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important symptoms across different diagnoses. Level 1 Cross-Cutting Measures entail surveys
that are brief, which include 12 domains for patients that are adolescents and children, while
those surveys for adult patients are 13 domains.
At the end of the biopsychosocial assessment, the questions that would need answers are
as follows; first, whether the patient is on any kind or form of medication second, whether the
patient's family carries a history of homicidal or suicidal ideologies. Third, the question as to
whether the patient has problems that are medically related that could be having a negative
impact on her life. Fourth, the question as to whether there exists a history, either family or
person, of the abuse of alcohol and drugs. Fifth, whether the patient does drugs or drinks alcohol.
These, among other significant questions, are essential in the assessment to establish the cause of
the problem the patient may be having and help determine a proper treatment plan and method.
Part two: Biopsychosocial Assessment
My assessment of Eliza's case in relation to symptomology is such that low self-esteem is
clearly manifested in the fact that she bends to pressure from her surroundings, making her do
things just because others are doing them. She does not have the confidence to make independent
decisions. In her defense to being asked if she drinks, she points out that she only drank because
the others were. Which means that she wouldn’t drink if they were not. The fact that she has
struggled to make friends can also be a reason for her low self-esteem. Eliza's anxiety is majorly
caused by the requirements for studying that she is faced with that are not as easy as she had in
High School in addition to other stressors like her friendship struggles. The Diagnostic and
Statistical Manual (DSM) and International Classification of Diseases play the role of identifying
and providing a classification of diseases after a diagnosis gets established (Cooper, R. (2018). In
Eliza's case, therefore, the diagnosis is that the patient is doubtful of her worth and abilities, and
ASSESSMENT AND INITIAL TREATMENT PLANNING
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she does not take a chance to explore her talents. The patient could be suffering from (BPD)
Borderline Personality Disorder, a condition that involves the patient struggling with low selfesteem negatively impacting her life (Paris, 2018). She also suffers from anxiety of a social
nature.
The goals for initial treatment include personal improvement, which will entail mending
interpersonal relationships. In this case, the relationship between Eliza and her parents, her
relationship with her schoolmates, and her attitude towards school. This will be a step in helping
her regain self-confidence and reduce stress and anxiety. The plan will entail establishing where
and when the sessions will be held as well as how frequent they will be, coming up with a crisis
plan, determining the availability of the clinician and setting a schedule, payment fees, and
billing get established and formulate the plan for treatment again when need be. We will also
ensure that Eliza is given guidance and advice and helped when solving problems that are of a
practical nature.
Part three: Treatment Planning
The Level 02 Cross-Cutting Measure (CCM-2) provides an intensive assessment of the
specific domains. The appropriate one for use in my future sessions, based on the information
provided above is LEVEL 2, Anxiety, Adult (PROMIS, Emotional Distress, Anxiety, Short
Form). This is because it addresses the specific issues, depression, and low self-esteem that the
patient happens to be suffering from.
Apart from the assessments provided by APA, the additional assessment that would be
appropriate for use by the future counselor would in assessing the best goals and plans for
treatment would be Generalized Anxiety Disorder Questionnaire -4 (GADQ)-4 which is a self-
ASSESSMENT AND INITIAL TREATMENT PLANNING
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report that is revised and therefore makes it possible for a patient to express their thoughts by
answering specific questions making it easier for the clinician to establish their mental state
(Hutchison et al., 2018). Therefore, it helps the clinician establish the appropriate diagnosis and
treatment mode.
In conveying the findings of my assessment to the family and the client, I will ensure that
I am sensitive to the feelings of the family and patient and consider their beliefs. As such, I will
be careful of my choice of words and communicate the findings in a delicate way to ensure that I
make the family and patient understand that there is a way of beating the problem by emulating
the suggested treatment forms. All this I will be doing at a private place. I will give the patient
and her family a chance to express their concerns and later respond to them in a way that they
can understand. I will give the patient and her family the various choices to decide what they
wish for after advising them accordingly. I will also make use of communication that is
nonverbal, show empathy to assure the patient and family of my support and willingness to help
them get past the problem.
I will prioritize the needs of the patient by stating the several options that are available for
their treatment, advising them on the most suitable form of treatment then letting them express
their opinion as to what they think is the best option for them. Engaging patients in decision
making is a strategy that significantly helps reduce healthcare costs as, in some cases, they
choose online engagements with doctors, which is cheaper. I will also prioritize their feelings in
terms of constantly checking on them and reassuring them that you are there for them when they
need you. Expressing compassion towards them and making them feel hopeful about their
condition so that they can have the will to work towards their recovery. I will formulate the
outcomes that we will have agreed upon by carrying out the treatments according to the
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stipulated plans of treatment. I will implement the strategies of treatment that will enable me to
achieve the goals set for the well-being of the patient. I will make use of the appropriate
measures to ensure the physical as the well emotional well-being of the patient.
Part Four: Referrals
The possible referrals I will make for the patient to help her manage the issues of
depression and self-esteem would be to have regular appointments with her counselors scheduled
to make sure that regular assessments get carried out to achieve improvements. I will also refer
her to a support group where she may meet individuals with similar experiences and understand
their journeys to recovery from the places they were to where they are. Meeting people who have
gotten through similar situations and experiences can help the patient understand that just like
they got through it, she can get through what she is going through too. Support groups are an
efficient way of building optimism in a patient so that they don’t feel like their situation is
hopeless.
I will address these referrals with my client by educating them on the impact they will
have on her recovery. I will provide the various options for referral to the patient and explain
them in detail so that the patient can understand what each referral entails in terms of their
specific characteristics. I will then engage the patient in making a decision as to which referral
will be most suitable and comfortable for her. This will make the whole process of treatment
easy to manage as the patient will have expressed the willingness to work towards recovery by
agreeing to see the various specialists.
Therefore I will ensure the [patient adheres to the referrals in the following ways. First, I
will communicate with the specialists and consult with them before sending the patient referral,
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this I will do by exchanging files containing the patient’s medical details so that the specialist
can understand the case as it is and what to expect from the patient after meeting her. Also, it
helps the specialists prepare in advance the appropriate way to approach the matter. To make
sure the patient does not fail to show up for appointments with the referral, I will send reminders
for appointments to the patient occasionally so that she does not forget her appointments with the
specialists. The reminders will also include follow up instructions and surveys to emphasize the
importance of those appointments.
I will know who the right referrals will be by conducting intensive research on the
various specialists in the field of practice, conduct thorough research on their specific
qualifications and what their specialties are, and look into the patients they have worked with
before to have a better understanding of their work quality. I will also establish their individual
personalities in terms of how they relate with patients by conducting face to face meetings and
ask specific questions related to the patient’s case. I will listen to their points of view and
evaluate each to establish the most suitable option for my patient.
ASSESSMENT AND INITIAL TREATMENT PLANNING
References
Bravo, A. J., Villarosa-Hurlocker, M. C., & Pearson, M. R. (2018). College student mental
health: An evaluation of the DSM–5 self-rated Level 1 cross-cutting symptom measure.
Psychological assessment, 30(10), 1382.
Cooper, R. (2018). Diagnosing the diagnostic and statistical manual of mental disorders.
Routledge.
Hutchison, T. E., Penney, A. M., & Crompton, J. E. (2018). Procrastination and anxiety:
Exploring the contributions of multiple anxiety-related disorders. Current Issues in
Personality Psychology, 6(2), 122-129.
Paris, J. (2018). Clinical features of borderline personality disorder. Handbook of Personality
Disorders: Theory, Research, and Treatment, 2, 419.
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ASSESSMENT AND INITIAL TREATMENT PLANNING
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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: ____________________________________________ Date: ______________ Age:______
DOB: __________________
DSM Diagnosis
ICD Diagnosis
Goals / Objectives:
□ Mood Stabilization
□ Anxiety Reduction
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
□ Reduce Obsessive Compulsive □ Psychotropic Medication Referral &
Behaviors
Consultation □ Journaling
□ Cognitive Behavior Therapy
□ Skill Training
□ Weekly □ Bi Weekly □
Monthly
□ other:
____________________
□ Group □ Individual □
Family
□ Decrease Sensitivity to
□ Verbalize Memories Triggers &
□ Weekly □ Bi Weekly □
© 2017. Grand Canyon University. All Rights Reserved.
Trauma Experiences
□ Establish and Maintain Eating
Disorder Recovery
□ Maintain Abstinence from
substances (Alcohol/Drugs)
Emotion
Monthly
□ Desensitize Trauma Triggers and
Memories
□ other:
____________________
□ Utilize Healing Model/Support
(Mending the Soul)
□ Group □ Individual □
Family
□ Overcome Denial □ Identify
Negative Consequences
□ 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
□ Decrease/Eliminate Self
Harmful Behaviors
□ Alleviate Distress
Behavior Therapy
□ Cognitive
□ Weekly □ Bi Weekly □
Monthly
□ Stress Management □ Skills
Training
□ other:
____________________
□ Improve Daily Functioning □
Develop Healthy Support
□ Group □ Individual □
Family
□ Cognitive Behavior Therapy □
Skills Training
□ Weekly □ Bi Weekly □
Monthly
© 2017. Grand Canyon University. All Rights Reserved.
□ 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.
Course Code
PCN-610
Class Code
PCN-610-O500
Criteria
Content
Percentage
70.0%
DSM/ ICD Diagnosis C1.5: Assess a client and
provide a justifiable diagnosis.
20.0%
Mental Health, Medical, Legal, and Substance
Use Issues
15.0%
Treatment Plan
20.0%
Treatment Theory
15.0%
Organization and Effectiveness
20.0%
Thesis Development and Purpose
7.0%
Argument Logic and Construction
8.0%
Mechanics of Writing (includes spelling,
punctuation, grammar, language use)
5.0%
Format
10.0%
Paper Format (use of appropriate style for the
major and assignment)
5.0%
Documentation of Sources (citations, footnotes,
references, bibliography, etc., as appropriate to
assignment and style)
5.0%
Total Weightage
100%
Assignment Title
Benchmark - Treatment Plan Completion and Essay (Obj. 5.2 and 5.4)
Unsatisfactory (0.00%)
Does not provide a DSM/ICD diagnosis.
Does not describe how to address any mental health,
medical, legal, and substance use issues that the client
exhibits.
Does not create a treatment plan.
Does not indicate a treatment theory.
Paper lacks any discernible overall purpose or organizing
claim.
Statement of purpose is not justified by the conclusion. The
conclusion does not support the claim made. Argument is
incoherent and uses noncredible sources.
Surface errors are pervasive enough that they impede
communication of meaning. Inappropriate word choice
and/or sentence construction are used.
Template is not used appropriately or documentation format
is rarely followed correctly.
Sources are not documented.
Total Points
110.0
Less than Satisfactory (74.00%)
Provides a DSM/ ICD diagnosis, but the diagnosis is missing
key elements necessary for creating an effective treatment
plan.
Describes how to address any mental health, medical, legal,
and substance use issues that the client exhibits in the case
study, but the information provided is inaccurate or vague.
Creates a treatment plan, but the plan is missing one of the
four main components (description of the problem, goals,
objectives, and interventions).
Indicates a treatment theory, but the rationale for using the
theory is vague or irrelevant.
Thesis and/or main claim are insufficiently developed and/or
vague; purpose is not clear.
Sufficient justification of claims is lacking. Argument lacks
consistent unity. There are obvious flaws in the logic. Some
sources have questionable credibility.
Frequent and repetitive mechanical errors distract the
reader. Inconsistencies in language choice (register) and/or
word choice are present. Sentence structure is correct but
not varied.
Appropriate template is used, but some elements are missing
or mistaken. A lack of control with formatting is apparent.
Documentation of sources is inconsistent or incorrect, as
appropriate to assignment and style, with numerous
formatting errors.
Satisfactory (79.00%)
Provides an accurate DSM/ICD diagnosis, but inadequately
provides citations.
Briefly describes how to address any mental health, medical,
legal, and substance use issues that the client exhibits.
Creates a treatment plan that includes all four main
components, and incorporates the client's strengths and
support system, but is missing key diagnostic information
necessary for inclusion in the treatment plan.
Indicates a treatment theory and provides a basic, but
relevant rational for using the theory.
Thesis and/or main claim are apparent and appropriate to
purpose.
Argument is orderly, but may have a few inconsistencies. The
argument presents minimal justification of claims. Argument
logically, but not thoroughly, supports the purpose. Sources
used are credible. Introduction and conclusion bracket the
thesis.
Some mechanical errors or typos are present, but are not
overly distracting to the reader. Correct and varied sentence
structure and audience-appropriate language are employed.
Appropriate template is used. Formatting is correct, although
some minor errors may be present.
Sources are documented, as appropriate to assignment and
style, although some formatting errors may be present.
Good (87.00%)
Provides an accurate DSM/ICD diagnosis that fully and
correctly cites the DSM/ICD.
Thoroughly describes how to address any mental health,
medical, legal, and substance use issues that the client
exhibits and provides examples to support the information
provided.
Creates a treatment plan that includes all four main
components and incorporates the client's strengths and
support system. All key diagnostic information is addressed in
the treatment plan.
Indicates a treatment theory and provides a thorough,
relevant explanation for using the theory.
Thesis and/or main claim are clear and forecast the
development of the paper. It is descriptive and reflective of
the arguments and appropriate to the purpose.
Argument shows logical progressions. Techniques of
argumentation are evident. There is a smooth progression of
claims from introduction to conclusion. Most sources are
authoritative.
Prose is largely free of mechanical errors, although a few may
be present. The writer uses a variety of effective sentence
structures and figures of speech.
Appropriate template is fully used. There are virtually no
errors in formatting style.
Sources are documented, as appropriate to assignment and
style, and format is mostly correct.
Excellent (100.00%)
Provides an accurate DSM/ICD diagnosis that fully and
correctly cites the DSM/ICD. Clearly illustrates the connection
between the primary, diagnosis, specifiers, and psychosocial
stressors.
Thoroughly describes how to address any mental health,
medical, legal, and substance use issues that the client
exhibits and provides examples and scholarly references to
support the information provided.
Creates a treatment plan that includes all four main
components and incorporates the client's strengths and
support system. All key diagnostic information is addressed in
the treatment plan. Illustrates a clear connection between
the problem and the goals, objectives and suggested
interventions provided.
Indicates a treatment theory and provides a thorough,
relevant explanation for using the theory. The rationale
provided is supported with scholarly references.
Thesis and/or main claim are comprehensive. The essence of
the paper is contained within the thesis. Thesis statement
makes the purpose of the paper clear.
Clear and convincing argument that presents a persuasive
claim in a distinctive and compelling manner. All sources are
authoritative.
Comments
Writer is clearly in command of standard, written, academic
English.
All format elements are correct.
Sources are completely and correctly documented, as
appropriate to assignment and style, and format is free of
error.
Points Earned
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