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.
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