PCN610 Grand Canyon Week 8 Alcohol Use Treatment Plan Paper

User Generated

tvaand

Humanities

PCN610

Grand Canyon University

Description

Details:

Part 1: Using the revised treatment plan completed in Topic 7, complete a discharge summary for your client using the "Discharge Summary" template. This discharge summary should address the following:

  1. What behaviors would indicate that the client is sustaining at a healthy baseline?
  2. How would you determine if Eliza met her treatment goals?
  3. What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?
  4. Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services? (Recommendations should be based on the information gathered for second mandatory evaluation).
  5. How would you encourage involvement in community-based resources?

Part 2: Write a 700-1,050-word summary statement about your client, Eliza.

Include or address the following in your summary statement:

  1. Demonstrate whether or not the client met the goals of the treatment plan.
  2. What specifically contributed to the success of the treatment plan or lack thereof?
  3. What language would you use to communicate the outcome to the client?
  4. How would you document the final session?
  5. Include at least three scholarly references in your paper.

PREVIOUS PAPERS/PLANS SUBMITTED AS WELL

Unformatted Attachment Preview

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: Resources and Referrals: [State the client's reason for discharge here.] [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 © 2017. Grand Canyon University. All Rights Reserved. Running head: Treatment Plan 1 Updated Treatment Plan for Eliza Irais Quijada GCU PCN-610 February 5, 2018 Running head: Treatment Plan 2 Updating a Treatment Plan A treatment plan should be considered a working document as it is developed around the problems that the client brings into therapy. As the counseling process develops and progresses, so does the client and with that can bring changes that may require counselors to reassess and update treatment plans to reflect those changes. Perkinson and Perkinson remind us “Treatment planning is a never-ending stream of therapeutic plans and interventions. It is always moving and changing” (Perkinson & Perkinson, 2017,p. 75). The following paper will analyze the recent changes with Eliza and update her treatment plan to reflect the appropriate changes. Updates to Treatment Plan Updates to Diagnosis Recently Eliza was sent back in for a mandatory evaluation after another alcohol related incident where Eliza was found passed out in her dorm and smelling of alcohol. Due to this incident directly following the initial reason for seeking mental health treatment, which also involved alcohol, Eliza will be evaluated for an Alcohol Use Disorder. According to the Diagnostic and Statistics Manual, fifth edition (DSM-5) Alcohol use disorder is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the set criteria listed in the DSM occurring in the same year (American Psychiatric Association & American Psychiatric Publishing, 2014). Two symptoms met include “Recurrent alcohol use leading to failure to fulfill major role obligations at work, school, or home” and “Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol” (American Psychiatric Association & American Psychiatric Publishing, 2014, p.491). At this time, the diagnosis for an AUD is listed Running head: Treatment Plan as mild but without treatment or a commitment to abstain an update in severity could be made. The next step would be to further assess Eliza’s alcohol use, in order to do so I may use the Alcohol Dependency Scale. Changes to Treatment Plan At this time, nothing was taken away from the original treatment plan, however, due to the recent changes in Eliza’s behavior and increased alcohol use two new goals were added along with new interventions. Eliza is at risk for a moderate to severe diagnosis of AUD if her alcohol consumption continues. In addition, Eliza is at risk of being removed from her studenthousing situation and could put her academic status at risk as well if her behaviors continue. As Eliza has stated she does not want to leave her dorm or her school, a goal to maintain abstinence from alcohol has been added. To support her in this, the interventions suggested are to work with the counselor in her weekly session on identifying the negative consequences that continued alcohol use could lead to. It is suspected that the AUD may have developed as a coping strategy to the original Adjustment Disorder, Eliza and counselor will need to focus on developing new healthy coping strategies. To increase Eliza’s awareness of AUD and help build a support system it is recommended that she attend group meetings for AUD at the student center every two weeks on Wednesday evenings. With the recent changes, Eliza’s mood has worsened stating that she feels ‘worthless’ because of the mistakes she is making. A goal has been added to improve on her self-worth thr9ough confidence building exercises during her weekly individual counseling sessions. The changes made are both ethically and legally justified as they are in adherence to the current diagnostic standards and as Eliza is still considered a minor not of drinking age. Potential Barriers to Treatment 3 Running head: Treatment Plan With the recent changes in Eliza’s behavior she now has co-occurring disorders, which can be more difficult to treat, and particularly in that one of those is an AUD. In general AUD disorders can be more difficult as we now need to prioritize treating the symptoms of the AUD in order to keep Eliza safe and be able to progress successfully through treatment. However, this can prove difficult as the American Addiction Centers explains “Though the symptoms of one disorder may predate the other, both disorders tend to exacerbate one another, making it impossible to extricate the symptoms caused by one disorder from the other (American Addiction Centers, 2015). In addition, denial and resistance can become barriers with this type of diagnosis making treatment problematic if Eliza is not willing to commit. Referral Process With the recent changes in Eliza’s need and diagnosis a referral could be made for alcohol abuse treatment. In order to make a referral that could work for Eliza I would need to take into consideration her financial means, transportation and current school commitments. Although her mental health is a priority I would be worried about putting more on her plate than she can handle or putting her in a situation where she must chose between attending class or a group. In communicating the need for the referral to Eliza I would explain my scope of practice and why I feel a referral is the best choice for her right now. Recommendations I would make would include a counselor with substance or alcohol abuse experience and group meetings. 4 Running head: Treatment Plan 5 References American Addiction Centers. (2015, October). Co-Occurring Disorders Treatment Guide | American Addiction Centers. Retrieved from https://americanaddictioncenters.org/cooccurring-disorders/ American Psychiatric Association, & American Psychiatric Publishing. (2014). Diagnostic and statistical manual of mental disorders: DSM-5. Washington: American Psychiatric Publishing. Perkinson, R. R., & Perkinson, R. R. (2017). Treatment Plan. In Chemical dependency counseling: A practical guide (p. 75). SAGE publications. Running head: Treatment Plan 6 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. Yellow is original treatment plan and updates have been highlighted green. Client: Eliza Doolittle Date: February 5, 2018 Age: 18 DSM Diagnosis ICD Diagnosis Adjustment Disorder (309.28) F43.23 Alcohol Use Disorder (305.00) Mild F10.10 Goals / Objectives: □ Mood Stabilization □ Anxiety Reduction Reduce anxiety and increase coping skills in responding to stress and anxiety DOB: January 2, 2000 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 Trauma Experiences □ Verbalize Memories Triggers & Emotion □ Weekly □ Bi Weekly □ Monthly □ Desensitize Trauma Triggers and Memories □ other: ____________________ □ Utilize Healing Model/Support □ Group □ Individual □ Running head: Treatment Plan 7 (Mending the Soul) 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 □ Maintain Abstinence from substances (Alcohol/Drugs) □ Substance Use Assessment □ Weekly □ Bi Weekly □ Step work □ Overcome Denial □ Monthly Individual therapy for identifying negative consequences □ Identify Negative Consequences □ other: ____________________ □ Establish and Maintain Eating Disorder Recovery Bi-weekly group meetings for Alcoholism prevention/support □ Increase Coping Skills □ Commitment to Recovery Program □ Attend Meetings □ Obtain Sponsor □ Family □ DBT Skills Training Increase Eliza’s ability to □ Problem Solving Techniques identify every day problems □ Emotion Recognition & Regulation and create solutions that can be □ Communication Skills accomplished □ Stabilize, Adjustment to New Life Circumstances Teach Eliza to identify stress triggers and techniques to respond to them. □ Decrease/Eliminate Self Harmful Behaviors □ Group □ Individual □ Alleviate Distress Behavior Therapy □ Cognitive □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Weekly □ Bi Weekly □ Monthly □ Stress Management □ Skills Training □ other: ____________________ □ Improve Daily Functioning □ Develop Healthy Supports □ Group □ Individual □ Family □ 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 □ Running head: Treatment Plan 8 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 Running head: TREATMENT PLAN 1 Treatment plan Name: Class: Tutor: Date: TREATMENT PLAN 2 Logic behind occurrence of changes The above changes in the initial treatment plan are driven by the fact that the client might have been adversely affected by the psychological problem; to the degree of exhibiting other manifestations that were not initially displayed. Other factors that might have led to these changes are the impact of the first initial proposed corrective measures for the problem that was affecting Eliza. Some of the proposed corrective technique might have failed to achieve the intended purpose (Osher, Kofoed 2006). The new environment in which the lady was exposed might have contributed to the emergency of other psycho-social problems that were not initially evident during the primary phase of treatment. The situation of the client seems to be deteriorating on daily basis. It is clear from the report from the university fraternity that the level of alcohol and other substance abuse have adversely affected her (Osher, Kofoed 2006). There are other healthy manifestations that are accompanying Eliza; substantiated by the fact that the level of drugs in her body system was too high. The conflicting situation at the university where Eliza is enrolled is wanting. The management team is concerned and is fully compelled to come up with the best effective and efficient contingency plans. It is the culture of prolonged and uncontrollable alcohol abuse that has caused changes to emerge in the plan to ensure that the situation is salvaged. Effectiveness of the treatment plan The proposed new plan is a holistic approach of addressing all psychological issues that were not initially identified in the primary treatment proposed plan. The plan is meant to address all important and key psychological deficiencies of the young lady. For example, key issues of concern such as depression management, anger management, adjusting to the new environment TREATMENT PLAN 3 and other key inclusions have been fully addressed. The frequency of applying the interventions of the set goals is designed in such as way that it is very flexible and complies with the special needs of the client (Osher, Kofoed 2006). Evidently, the plan is fully designed and tailored in a scientific and psychological angle of inclination; to address the issues of eminent substance and drug abuse at the university; where Eliza is a student. From the official report by the evaluation team, drug abuse is the major psychological problem that has had incapacitations to Eliza (McLellan et al. 2009). Plan adjustment As I have stated in the above paragraphs, alcohol abuse is a mega problem that is jeopardizing the peaceful academic and personality traits of the university student. The current treatment plan should be fully tailored to meet the special needs of substance abuse of Eliza. The plan should be focusing on key aspects of the client such as prevention, screening, actual assessment, diagnosis and final medical interventions to fully address the issue. The plan should be adjusted to include the aspects of work and motivation in order to create a sense of humanity in the university student; who is fighting the menace of drug and substance abuse (McLellan et al. 2009). Ethical and legal changes in the treatment plan Due to the change of events in the original proposed plan, there are some new issues that should be considered during the actual process of dealing with the issue of alcohol abuse of the client. Ethically, the treatment plan has to be confidential. This is due to the fact that the level of alcohol abuse in the client has sky-rocketed (Mclellan et al. 1980). Nothing should be exposed to irrelevant parties so that the client does not feel that her privacy has been compromised. TREATMENT PLAN 4 The plan is in full compliance with legal stipulations of the respecting the client’s self determination (Mclellan et al. 1980). The plan is not meant to compel her to issue information that is out of her beliefs. The process should be done in compliance with the informed consent, the duty of professional psychologists to care and application of the credential mechanisms in treating the state of alcohol abuse of the client. Obstacles to treatment plan Sometimes, the client might to be able to feel free to express herself on the exact problem forcing her to indulge in prolonged drug abuse. The inability to be transparency is likely to jeopardize the credible outcome of the proposed treatment plan. Finance can pose another huge problem to the current treatment plan (Mclellan et al. 1980). In the event that funds are not sufficient enough, the client might not be able to access specialized medical treatment. TREATMENT PLAN 5 References Fred C. Osher and Lial L. Kofoed (2006). Treatment of Patients with Psychiatric and Psychoactive Substance Abuse Disorders. Published online: April 01, 2006 https://doi.org/10.1176/ps.40.10.1025 Mclellan, A Thomas Ph.D.; Luborsky, Lester Ph.D.; Woody, George E. M.D.; O & Apos; Brien, Charles P. M.D., Ph.D. (1980). An Improved Diagnostic Evaluation Instrument for Substance Abuse Patients: The Addiction Severity Index. Journal of Nervous & Mental Disease: January 1980 Thomas McLellan, Isabelle O. Arndt David S. Metzger & George E. Woody Charles P. O'Brlen (2009). The Effects of Psychosocial Services in Substance Abuse Treatment. Pages 38-47 | published online: 12 Jul 2009. Running head: TREATMENT PLAN 1 Initial Treatment Plan: Eliza Irais Quijada GCU PCN-610 January 17, 2017 Running head: TREATMENT PLAN 2 Initial Treatment Planning: Eliza The following paper will look at an initial treatment plan for client, Eliza. Eliza is an 18-year-old student living on campus with roommates and has decided to seek out counseling due to anxiety, stress and low self-esteem. To better understand the process a client goes through when seeking out mental health services, the paper will focus on the intake, assessment, and treatment planning and referral procedures for Eliza. Intake Upon arrival Eliza was given an intake document to help with identifying information, presenting problems, immediate risks and brief family information. Eliza reports that she is seeking out counseling because she has to. At this time, her presenting problems do not present an immediate risk. Eliza reports having a ‘okay’ relationship with her mother, an elementary school teacher and a ‘good’ relationship with her father, who is a truck driver. Eliza reports no current life stressors or medications for mental health. The next step will be to conduct a more thorough assessment looking at biological, psychological and social factors that could help in understanding Eliza and her presenting problems. Biopsychosocial Assessment Using the biopsychosocial (BPS) framework and assessment helps to look at a client in a more holistic way; addressing areas such as their genetic information, the behavior and their cultural or familial backgrounds. In Eliza’s case the BPS model can be particularly beneficial as it has illustrated its importance in the treatment of disorders such as anxiety (Meyer, 2008), which is a presenting symptom of Eliza’s at this time. Running head: TREATMENT PLAN Identifying Information Eliza is a Caucasian female attending her freshman year of college as a engineering major. Her family resides in a town that is approximately two hours away. Presenting Problems Eliza is here because ‘she has to be’ due to an issue with residential advisor (RA) and her on campus living agreement (discussed further under substance use). She presents with substance use, anxiety, stress and low self-esteem concerns. Life Stressors Eliza denies feeling lonely but states it is difficult to make friends. She identifies school as a stressor as it has proven to much harder in high school and has difficulty with the increased study requirements. Substance Use and Abuse Eliza is presenting with substance use. She reports having to come to counseling because she lives in an alcohol-free campus dorm and was recently caught by her RA with alcohol in her room along with some friends who were intoxicated. Eliza states that she was “just buzzed” and drinking “because they were” and “its just something to do”. Client denies having a drug or alcohol problem. Reports trying marijuana once and not liking it, alcohol use started in high school and reports only drinking occasionally on weekends but does not feel she drinks in excess. Addictions 3 Running head: TREATMENT PLAN No current addictions were identified. Eliza stated she plays an online game once or twice a week for approximately three to five hours. Medical, Mental Health and Hospitalizations At this time Eliza states there is not past mental health concerns or hospitalizations. Abuse and Trauma Eliza states that there is no current or past abuse to report but that she did experience teasing in high school but opted to not discuss this further. Social Relationships Eliza feels that she has quality relationships but adds that she often feels taken advantage of by them. Details include friends asking her to complete their homework and host parties in her dorm. She has not talked to her friends about her concerns, stating “its not that big of a deal”. Family Information Eliza is the only child and relates to her mother as ‘controlling’ and her father as ‘a good guy’. Growing up her mother was vigilant and questioning of her activities and whereabouts and her mother still requires once a week phone calls “or else she gets worried”. Eliza feels her parent’s relationship is strained and recalls feeling caught in the middle when she lived at home and her parents complain to her about their marriage. Spiritual Eliza identifies as agnostic and her parents identify as Irish Catholic, usually only attending church on Christmas and Easter. Suicidal 4 Running head: TREATMENT PLAN Eliza denies feeling suicidal and does not appear to fit criteria for concern. Homicidal Eliza does not present with homicidal concerns at this time. Results and Treatment After reviewing Eliza’s intake and biopsychosocial assessment, she appeared to difficulty with anxiety and some substance use. The next step in her treatment process will include having Eliza take the Diagnostic and Statistic Manual’s (DSM-5) Self-Rated Level 1 Cross Cutting Symptom Measure for adults in addition to continued counseling sessions one time per week. Treatment Planning The results from the Level-1 Cross-Cutting Measure showed a concern under the domain for Anxiety Disorders, scoring a mild or greater (American Psychiatric Association & American Psychiatric Publishing, 2014). The next step in her treatment process will be to move onto the Level-2 (PROMIS Emotional Distress-Anxiety-Short Form) s recommended by the Level-1 Cross-Cutting Measure in order to gather more information about Eliza’s anxiety. In addition I would also suggest using the Generalized Anxiety Disorder 7-Item (GAD-7) Scale for the purpose of further screening for anxiety disorders. Screening tools such as these are important to the diagnostic and treatment process as it allows for a better understanding of what is going on with the client and specific areas for concern to provide an accurate diagnosis (SAMHSA, 2018). Results will be shared with Eliza alone unless she would like her parents present, but as she is considered an adult her treatment is private and protected by her client rights The treatment plan will consists of identifying a potential support system, creating a schedule 5 Running head: TREATMENT PLAN for studying and leisure time as well as an agreement to keep alcohol out of her dorm room. Treatment goals at this time will include a weekly session, keeping a daily journal to report moments of anxiety as well as a couple mindfulness exercises to do at home. The priority would be the agreement to keep alcohol out of her dorm and to stick to a schedule for her studying and leisure time. I would convey to Eliza the importance of communicating with me if the schedule at any time is no longer working for her, it is important this is something she can do with east and does not become another burden on her. Referral Process At this time, without the results of the Level-2 PROMIS and the GAD-7 I would not feel a referral is necessary. However if the results came back with a type of anxiety disorder that was outside my experience or expertise I would consult with my supervisor to see if this is setting is still a good fit and if it is not we would work around things such as her location, insurance and financial abilities to make an appropriate referral. Some counselors feel “that they owe no further duty to the patient” (CPH and Associates, 2005) once the proper steps for the referral have been completed. However, some counselors feel there are circumstances where follow up is important for the clients well being. In this case, a call can be made for example to check in with Eliza and make sure the referral process was successful. 6 Running head: TREATMENT PLAN 7 References American Psychiatric Association, & American Psychiatric Publishing. (2014). Diagnostic and statistical manual of mental disorders: DSM-5. Washington: American Psychiatric Publishing. CPH and Associates. (2005, May). Duty to the Patient. Termination and Referral When Does the Duty to the Patient End? Retrieved from https://www.cphins.com/termination-and-referral-when-does-the-duty-to-thepatient-end/ Meyer, L. (2008). The use of a comprehensive biopsychosocial framework for intake assessment in mental health practice. Dissertations (1962 - 2010) Access via Proquest Digital Dissertations. AAI3326743.. Retrieved from http://epublications.marquette.edu/dissertations/AAI3326743/ SAMHSA. (2018). Screening Tools. Retrieved from https://www.integration.samhsa.gov/clinical-practice/screening-tools#anxiety Schwitzer, A. M., & Rubin, L. C. (2015). Diagnosis & treatment planning skills: A popular culture casebook approach. Psychosocial Assessment Template ____ Part 1 (Topic 2) ____ Part 2 (Topic 3) Name: David___________________________ Date: _12-20-2017______ DOB: _1968____________ Age: _49_______________________________ Start Time: _10:00am_ End Time: __11:00am____ Identifying Information: David is a married 49-year-old male, with two children. David met his wife in high school and has been married for 21 years. David descries their relationship as “typical” meaning that they have meals together and attend family functions together but outside of this do very little as a couple. He has been employed as a metallurgical engineer for 20 years. David has a sister named Lisa who has struggles with depression for over 10 years. Presenting Problem: Presenting problems include; changes in mood such as loss of enjoyment in work and relationship with spouse. David reports a withdrawal from preferred hobbies such as reading, playing gold and watching TV. Instead, for the last six months, David has preferred to be alone. David reports feeling ‘blue’ and has been having difficulty sleeping and eating due to a loss of appetite. David complains he feels irritable and with low energy. Life Stressors: Life stressors can include his loss of enjoyment in every day activities such as his family relationships, spousal relationship and work. This is compounded with the physical pain he has been experiencing in his back and neck. In addition, his sisters depression may also be considered a life stressor as she often has a negatice outlook on things that she shares with David. Substance Use/Abuse: Yes No David Reports having two or three beers a night but mentions that he drank more frequently when he was younger. Addictions (i.e., gambling, pornography, video gaming) No addictions aare mentioned at this time Medical/Mental Health Hx/Hospitalizations: Medically, David reports physical pain in his back and neck. David reports the onset of his change in mood and behavior occurring over the last six months. No other personal history or hospitalizations are reported this time. David’s living sister has struggles with depression and is currently seeing a psychiatrist. Abuse/Trauma: David did not report abuse or trauma. However David’s nightly consumption of a few beers a night could be a dependency and be considered problematic. Social Relationships: As David has withdrawn over the last six months, preferring to spend his time alone his relationships with family members, his spouse and coworkers are not as they once were. David’s Psychosocial Assessment Template ____ Part 1 (Topic 2) ____ Part 2 (Topic 3) change in how he once enjoyed going to work, playing gold and spending time with others has likely caused his social relationships to suffer. Family Information: David has a spouse of 21 years, two adult children and a sister. Spiritual: No Spiritual information was provided. Suicidal: David has not reported any incidents of attempting suicide or a plan of how he might do it. However, suicide is a concern as he reported that he has sometimes feels “life is hardly worth living”. Homicidal: At this time David does not present homicidal. ____________________________________________ Assessment: The assessment tool used to assess David for a possible diagnosis was the Diagnostic and Statistic Manual (DSM-5) Self-Rated Level 1 Cross-Cutting Symptom Measure- Adult version. Initial Diagnosis (DSM): Based on the results from the Cross-Cutting Symptom measure the domains that showed concern included domains one, two, five and eight which include Depression, Anger, Somatic Symptoms and Sleep Problems. Based on the results from the interview and assessment the initial diagnosis would be Depression as it meets the criteria listed in the DSM-5. The met criteria includes; depressed mood or a loss of interest or pleasure in daily activities for more than two weeks, mood represents a change from the person's baseline, impaired function: social, occupational, educational and specific symptoms (at least 5 of these 9, present nearly every day) Decreased interest or pleasure, change in sleep, change in activity, loss of energy, depressed mood and irritability. Initial Treatment Goals: Taking consideration of David’s baseline prior to the onset of symptoms things I would like to see are an increase in enjoyment of everyday activities such as his family interactions, work and participation in leisure activities. Goals may include: • Increasing understanding of depressive feelings: identify antecedents, triggers and consequences • Address the depression (underlying causes and concerns): Acceptance of the depression, identifying issues that may be contributing to the depression. Correct irrational thoughts or thinking • Identify harmful coping behaviors: Isolating/withdrawing or substance abuse) Psychosocial Assessment Template • ____ Part 1 (Topic 2) ____ Part 2 (Topic 3) Coping skills: decrease the extreme symptoms by improving coping skills to reduce depression and replace faulty coping strategies Plan: David will create a safety plan with his counselor in case thoughts or feelings of suicide return at any point. David will actively participate in his treatment by participating in individual or group therapy two times per week. David will use the support of the counselor and other identified supports such as his spouse and son to reduce his isolation. The treatment plan will be revisited monthly to adjust as needed or continue on the same course. Name: Irais Quijada Date: January 10, 2018 Psychosocial Assessment Template ____ Part 1 (Topic 2) ____ Part 2 (Topic 3) References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed). Running head: Treatment Plan 1 Updated Treatment Plan for Eliza Irais Quijada GCU PCN-610 February 5, 2018 Running head: Treatment Plan 2 Updating a Treatment Plan A treatment plan should be considered a working document as it is developed around the problems that the client brings into therapy. As the counseling process develops and progresses, so does the client and with that can bring changes that may require counselors to reassess and update treatment plans to reflect those changes. Perkinson and Perkinson remind us “Treatment planning is a never-ending stream of therapeutic plans and interventions. It is always moving and changing” (Perkinson & Perkinson, 2017,p. 75). The following paper will analyze the recent changes with Eliza and update her treatment plan to reflect the appropriate changes. Updates to Treatment Plan Updates to Diagnosis Recently Eliza was sent back in for a mandatory evaluation after another alcohol related incident where Eliza was found passed out in her dorm and smelling of alcohol. Due to this incident directly following the initial reason for seeking mental health treatment, which also involved alcohol, Eliza will be evaluated for an Alcohol Use Disorder. According to the Diagnostic and Statistics Manual, fifth edition (DSM-5) Alcohol use disorder is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress as manifested by at least two of the set criteria listed in the DSM occurring in the same year (American Psychiatric Association & American Psychiatric Publishing, 2014). Two symptoms met include “Recurrent alcohol use leading to failure to fulfill major role obligations at work, school, or home” and “Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol” (American Psychiatric Association & American Psychiatric Publishing, 2014, p.491). At this time, the diagnosis for an AUD is listed Running head: Treatment Plan as mild but without treatment or a commitment to abstain an update in severity could be made. The next step would be to further assess Eliza’s alcohol use, in order to do so I may use the Alcohol Dependency Scale. Changes to Treatment Plan At this time, nothing was taken away from the original treatment plan, however, due to the recent changes in Eliza’s behavior and increased alcohol use two new goals were added along with new interventions. Eliza is at risk for a moderate to severe diagnosis of AUD if her alcohol consumption continues. In addition, Eliza is at risk of being removed from her studenthousing situation and could put her academic status at risk as well if her behaviors continue. As Eliza has stated she does not want to leave her dorm or her school, a goal to maintain abstinence from alcohol has been added. To support her in this, the interventions suggested are to work with the counselor in her weekly session on identifying the negative consequences that continued alcohol use could lead to. It is suspected that the AUD may have developed as a coping strategy to the original Adjustment Disorder, Eliza and counselor will need to focus on developing new healthy coping strategies. To increase Eliza’s awareness of AUD and help build a support system it is recommended that she attend group meetings for AUD at the student center every two weeks on Wednesday evenings. With the recent changes, Eliza’s mood has worsened stating that she feels ‘worthless’ because of the mistakes she is making. A goal has been added to improve on her self-worth thr9ough confidence building exercises during her weekly individual counseling sessions. The changes made are both ethically and legally justified as they are in adherence to the current diagnostic standards and as Eliza is still considered a minor not of drinking age. Potential Barriers to Treatment 3 Running head: Treatment Plan With the recent changes in Eliza’s behavior she now has co-occurring disorders, which can be more difficult to treat, and particularly in that one of those is an AUD. In general AUD disorders can be more difficult as we now need to prioritize treating the symptoms of the AUD in order to keep Eliza safe and be able to progress successfully through treatment. However, this can prove difficult as the American Addiction Centers explains “Though the symptoms of one disorder may predate the other, both disorders tend to exacerbate one another, making it impossible to extricate the symptoms caused by one disorder from the other (American Addiction Centers, 2015). In addition, denial and resistance can become barriers with this type of diagnosis making treatment problematic if Eliza is not willing to commit. Referral Process With the recent changes in Eliza’s need and diagnosis a referral could be made for alcohol abuse treatment. In order to make a referral that could work for Eliza I would need to take into consideration her financial means, transportation and current school commitments. Although her mental health is a priority I would be worried about putting more on her plate than she can handle or putting her in a situation where she must chose between attending class or a group. In communicating the need for the referral to Eliza I would explain my scope of practice and why I feel a referral is the best choice for her right now. Recommendations I would make would include a counselor with substance or alcohol abuse experience and group meetings. 4 Running head: Treatment Plan 5 References American Addiction Centers. (2015, October). Co-Occurring Disorders Treatment Guide | American Addiction Centers. Retrieved from https://americanaddictioncenters.org/cooccurring-disorders/ American Psychiatric Association, & American Psychiatric Publishing. (2014). Diagnostic and statistical manual of mental disorders: DSM-5. Washington: American Psychiatric Publishing. Perkinson, R. R., & Perkinson, R. R. (2017). Treatment Plan. In Chemical dependency counseling: A practical guide (p. 75). SAGE publications. Running head: Treatment Plan 6 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. Yellow is original treatment plan and updates have been highlighted green. Client: Eliza Doolittle Date: February 5, 2018 Age: 18 DSM Diagnosis ICD Diagnosis Adjustment Disorder (309.28) F43.23 Alcohol Use Disorder (305.00) Mild F10.10 Goals / Objectives: □ Mood Stabilization □ Anxiety Reduction Reduce anxiety and increase coping skills in responding to stress and anxiety DOB: January 2, 2000 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 Trauma Experiences □ Verbalize Memories Triggers & Emotion □ Weekly □ Bi Weekly □ Monthly □ Desensitize Trauma Triggers and Memories □ other: ____________________ □ Utilize Healing Model/Support □ Group □ Individual □ Running head: Treatment Plan 7 (Mending the Soul) 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 □ Maintain Abstinence from substances (Alcohol/Drugs) □ Substance Use Assessment □ Weekly □ Bi Weekly □ Step work □ Overcome Denial □ Monthly Individual therapy for identifying negative consequences □ Identify Negative Consequences □ other: ____________________ □ Establish and Maintain Eating Disorder Recovery Bi-weekly group meetings for Alcoholism prevention/support □ Increase Coping Skills □ Commitment to Recovery Program □ Attend Meetings □ Obtain Sponsor □ Family □ DBT Skills Training Increase Eliza’s ability to □ Problem Solving Techniques identify every day problems □ Emotion Recognition & Regulation and create solutions that can be □ Communication Skills accomplished □ Stabilize, Adjustment to New Life Circumstances Teach Eliza to identify stress triggers and techniques to respond to them. □ Decrease/Eliminate Self Harmful Behaviors □ Group □ Individual □ Alleviate Distress Behavior Therapy □ Cognitive □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Weekly □ Bi Weekly □ Monthly □ Stress Management □ Skills Training □ other: ____________________ □ Improve Daily Functioning □ Develop Healthy Supports □ Group □ Individual □ Family □ 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 □ Running head: Treatment Plan 8 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 Running head: TREATMENT PLAN 1 Initial Treatment Plan: Eliza Irais Quijada GCU PCN-610 January 17, 2017 Running head: TREATMENT PLAN 2 Initial Treatment Planning: Eliza The following paper will look at an initial treatment plan for client, Eliza. Eliza is an 18-year-old student living on campus with roommates and has decided to seek out counseling due to anxiety, stress and low self-esteem. To better understand the process a client goes through when seeking out mental health services, the paper will focus on the intake, assessment, and treatment planning and referral procedures for Eliza. Intake Upon arrival Eliza was given an intake document to help with identifying information, presenting problems, immediate risks and brief family information. Eliza reports that she is seeking out counseling because she has to. At this time, her presenting problems do not present an immediate risk. Eliza reports having a ‘okay’ relationship with her mother, an elementary school teacher and a ‘good’ relationship with her father, who is a truck driver. Eliza reports no current life stressors or medications for mental health. The next step will be to conduct a more thorough assessment looking at biological, psychological and social factors that could help in understanding Eliza and her presenting problems. Biopsychosocial Assessment Using the biopsychosocial (BPS) framework and assessment helps to look at a client in a more holistic way; addressing areas such as their genetic information, the behavior and their cultural or familial backgrounds. In Eliza’s case the BPS model can be particularly beneficial as it has illustrated its importance in the treatment of disorders such as anxiety (Meyer, 2008), which is a presenting symptom of Eliza’s at this time. Running head: TREATMENT PLAN Identifying Information Eliza is a Caucasian female attending her freshman year of college as a engineering major. Her family resides in a town that is approximately two hours away. Presenting Problems Eliza is here because ‘she has to be’ due to an issue with residential advisor (RA) and her on campus living agreement (discussed further under substance use). She presents with substance use, anxiety, stress and low self-esteem concerns. Life Stressors Eliza denies feeling lonely but states it is difficult to make friends. She identifies school as a stressor as it has proven to much harder in high school and has difficulty with the increased study requirements. Substance Use and Abuse Eliza is presenting with substance use. She reports having to come to counseling because she lives in an alcohol-free campus dorm and was recently caught by her RA with alcohol in her room along with some friends who were intoxicated. Eliza states that she was “just buzzed” and drinking “because they were” and “its just something to do”. Client denies having a drug or alcohol problem. Reports trying marijuana once and not liking it, alcohol use started in high school and reports only drinking occasionally on weekends but does not feel she drinks in excess. Addictions 3 Running head: TREATMENT PLAN No current addictions were identified. Eliza stated she plays an online game once or twice a week for approximately three to five hours. Medical, Mental Health and Hospitalizations At this time Eliza states there is not past mental health concerns or hospitalizations. Abuse and Trauma Eliza states that there is no current or past abuse to report but that she did experience teasing in high school but opted to not discuss this further. Social Relationships Eliza feels that she has quality relationships but adds that she often feels taken advantage of by them. Details include friends asking her to complete their homework and host parties in her dorm. She has not talked to her friends about her concerns, stating “its not that big of a deal”. Family Information Eliza is the only child and relates to her mother as ‘controlling’ and her father as ‘a good guy’. Growing up her mother was vigilant and questioning of her activities and whereabouts and her mother still requires once a week phone calls “or else she gets worried”. Eliza feels her parent’s relationship is strained and recalls feeling caught in the middle when she lived at home and her parents complain to her about their marriage. Spiritual Eliza identifies as agnostic and her parents identify as Irish Catholic, usually only attending church on Christmas and Easter. Suicidal 4 Running head: TREATMENT PLAN Eliza denies feeling suicidal and does not appear to fit criteria for concern. Homicidal Eliza does not present with homicidal concerns at this time. Results and Treatment After reviewing Eliza’s intake and biopsychosocial assessment, she appeared to difficulty with anxiety and some substance use. The next step in her treatment process will include having Eliza take the Diagnostic and Statistic Manual’s (DSM-5) Self-Rated Level 1 Cross Cutting Symptom Measure for adults in addition to continued counseling sessions one time per week. Treatment Planning The results from the Level-1 Cross-Cutting Measure showed a concern under the domain for Anxiety Disorders, scoring a mild or greater (American Psychiatric Association & American Psychiatric Publishing, 2014). The next step in her treatment process will be to move onto the Level-2 (PROMIS Emotional Distress-Anxiety-Short Form) s recommended by the Level-1 Cross-Cutting Measure in order to gather more information about Eliza’s anxiety. In addition I would also suggest using the Generalized Anxiety Disorder 7-Item (GAD-7) Scale for the purpose of further screening for anxiety disorders. Screening tools such as these are important to the diagnostic and treatment process as it allows for a better understanding of what is going on with the client and specific areas for concern to provide an accurate diagnosis (SAMHSA, 2018). Results will be shared with Eliza alone unless she would like her parents present, but as she is considered an adult her treatment is private and protected by her client rights The treatment plan will consists of identifying a potential support system, creating a schedule 5 Running head: TREATMENT PLAN for studying and leisure time as well as an agreement to keep alcohol out of her dorm room. Treatment goals at this time will include a weekly session, keeping a daily journal to report moments of anxiety as well as a couple mindfulness exercises to do at home. The priority would be the agreement to keep alcohol out of her dorm and to stick to a schedule for her studying and leisure time. I would convey to Eliza the importance of communicating with me if the schedule at any time is no longer working for her, it is important this is something she can do with east and does not become another burden on her. Referral Process At this time, without the results of the Level-2 PROMIS and the GAD-7 I would not feel a referral is necessary. However if the results came back with a type of anxiety disorder that was outside my experience or expertise I would consult with my supervisor to see if this is setting is still a good fit and if it is not we would work around things such as her location, insurance and financial abilities to make an appropriate referral. Some counselors feel “that they owe no further duty to the patient” (CPH and Associates, 2005) once the proper steps for the referral have been completed. However, some counselors feel there are circumstances where follow up is important for the clients well being. In this case, a call can be made for example to check in with Eliza and make sure the referral process was successful. 6 Running head: TREATMENT PLAN 7 References American Psychiatric Association, & American Psychiatric Publishing. (2014). Diagnostic and statistical manual of mental disorders: DSM-5. Washington: American Psychiatric Publishing. CPH and Associates. (2005, May). Duty to the Patient. Termination and Referral When Does the Duty to the Patient End? Retrieved from https://www.cphins.com/termination-and-referral-when-does-the-duty-to-thepatient-end/ Meyer, L. (2008). The use of a comprehensive biopsychosocial framework for intake assessment in mental health practice. Dissertations (1962 - 2010) Access via Proquest Digital Dissertations. AAI3326743.. Retrieved from http://epublications.marquette.edu/dissertations/AAI3326743/ SAMHSA. (2018). Screening Tools. Retrieved from https://www.integration.samhsa.gov/clinical-practice/screening-tools#anxiety Schwitzer, A. M., & Rubin, L. C. (2015). Diagnosis & treatment planning skills: A popular culture casebook approach.
Purchase answer to see full attachment
User generated content is uploaded by users for the purposes of learning and should be used following Studypool's honor code & terms of service.

Explanation & Answer

Attached.
Find attached the completed workLooking forward to working with you againThank you

Running head: DISCHARGE SUMMARY STATEMENT

Discharge Summary Statement
Name
Institution

1

DISCHARGE SUMMARY STATEMENT

2

Discharge Summary Statement
The treatment plan for Eliza aimed to help her with the alcohol use tendencies that
provided trouble for her residing in the alcohol-free dorms on campus. Therefore, the treatment
plan initially aimed to help her limit alcohol use especially in the dorm deemed to have been
caused by her adjustment disorder. However, the plan further developed to include more goals
such as alcohol abstinence upon the realization that the alcoholism problem was getting worse
with time. The treatment plan was a good opportunity to interact with the client on a one-on-one
basis to understand and deal with the core issues she was facing. The sustainability of a healthy
baseline was the target of the interventions and the entire treatment plan. In the final session,
letting the client know that they did well by going through the treatment would boost their selfesteem and encourage further seeking help.
Eliza’s main problems included the adjustment to the campus environment and breaking
the alcohol use in dormitories. The change in behavior to indicate a healthy baseline would
mostly be through a recorded longer sobriety period, abstinence from alcohol; especially in the
campus dorms, and reported a feeling of ...


Anonymous
I use Studypool every time I need help studying, and it never disappoints.

Studypool
4.7
Trustpilot
4.5
Sitejabber
4.4

Similar Content

Related Tags