Treatment Plan Eliza

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Complete treatment plan template for Eliza based on the previous assignments findings and any feedback received from your instructor. Additionally, write an essay that includes the following:

  1. The treatment theory you would use and why.
  2. A description of how you would address any mental health, medical, legal, and substance use issues that the client exhibits in the case study through the lens of your counseling theory of choice.
  3. Include at least three scholarly sources in your paper, including

Schwitzer, A., & Rubin, L. (2015). Diagnosis & Treatment Planning Skills. Thousand Oaks: Sage Publishcations Inc.

  • Additional comments to follow during the week.
    • Prof. notes from Eliza paper.
    • ?

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Treatment Plan Based on the information collected, complete the following treatment plan for your client Eliza. Be sure to include a description of the problem, goals, objectives, and interventions. Remember to incorporate the client's strengths and support system in the treatment plan. Client: ____________________________________________ Date: ______________ Age:______ DOB: __________________ DSM Diagnosis Goals / Objectives: □ Mood Stabilization □ Anxiety Reduction ICD Diagnosis 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 □ other: □ Establish and Maintain Eating Disorder Recovery □ Maintain Abstinence from substances (Alcohol/Drugs) Memories ____________________ □ Utilize Healing Model/Support (Mending the Soul) □ Group □ Individual □ Family □ Overcome Denial □ Identify Negative Consequences □ Weekly □ Bi Weekly □ Monthly □ Menu Planning □ Nutrition Counseling □ Body Image Work □ other: ____________________ □ Healthy Exercise □ Trigger Mngmt Recovery Plan □ CBT □ Group □ Individual □ Family □ Substance Use Assessment □ Stepwork □ Overcome Denial □ Identify Negative Consequences □ Commitment to Recovery Program □ Attend Meetings □ Obtain Sponsor □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Increase Coping Skills □ DBT Skills Training □ Problem Solving Techniques □ Weekly □ Bi Weekly □ Monthly □ Emotion Recognition & Regulation □ Communication Skills □ other: ____________________ □ Group □ Individual □ Family □ Stabilize, Adjustment to New Life Circumstances □ Decrease/Eliminate Self Harmful Behaviors □ Alleviate Distress Behavior Therapy □ Cognitive □ Weekly □ Bi Weekly □ Monthly □ Stress Management □ Skills Training □ other: ____________________ □ Improve Daily Functioning □ Develop Healthy Support □ Group □ Individual □ Family □ Cognitive Behavior Therapy □ Skills Training □ Weekly □ Bi Weekly □ Monthly □ Develop and Utilize Support System □ other: ____________________ □ Group □ Individual □ Family □ Improve Relationships □ Communication Skills □ Active Listening □ Family Therapy □ Assertiveness □ Setting Healthy Boundaries □ Weekly □ Bi Weekly □ Monthly □ other: ____________________ □ Group □ Individual □ Family □ Improve Self Worth □ Affirmation Work □ Positive Self Talk □ Skills Training □ Weekly □ Bi Weekly □ Monthly □ Confidence Building Tasks □ other: ____________________ □ Group □ Individual □ Family □ Grief Reduction and Healing from Loss □ Develop Anger Management Skills □ Psychoeducation on Grief Process/ Stages □ Weekly □ Bi Weekly □ Monthly □ Process Feeling □ Emotion Regulation Techniques □ other: ____________________ □ Reading/Writing Assignments □ Develop/Utilize Support □ Group □ Individual □ Family □ Decrease Anger Outbursts □ Emotion Regulation Techniques □ Cognitive Behavior Therapy □ Weekly □ Bi Weekly □ Monthly □ Increase Awareness/Self Control □ other: ____________________ □ Group □ Individual □ Family Running Head: INITIAL TREATMENT: ELIZA Initial Treatment: Eliza Grand Canyon University PCN- 610 Travis Foley December 05, 2017 1 Eliza 2 Eliza Introduction The Psychosocial Assessment is an important document, which sets up the foundation for the future work. Through observations and clinical interview, the counselor is able to develop a descriptive assessment to understand the client’s experiences and assist the diagnostic process. A psychological assessment involves evaluation of patient’s mental health as well as social wellbeing. The assessment checks the clients state of mental health, which entails being able to overcome the stresses of life, and work. As well as being able to perform productively in the community. Mental illness is manipulated by some behaviors which shows a person is in trouble, i.e.: stressed. A number of factors including work activities, life encounters, and state of the community they live may contribute the illness. Psychological assessment assesses personal perception and one's ability to perform in the community. In the psychological assessment, the patient is asked some questions to ascertain a number of domains or issues (PsychGuides, 2016). This helps to understand the patients well in order to provide the best suitable healthcare service. Psychological assessment is very import activity as far as nursing care of a patient is involved. Part 1: Intake The basic segments of a psychosocial assessment include identifying the patient, the main complainant, the historical backdrop of the illness presented, and the mental wellness history. Along with medicinal or surgical history, medical prescription notes, alcohol use, drug use. A violence behavior assessment, family history, social record, occupational information, education background, development history, cultural information, financial information are involved in the Eliza 3 psychosocial assessment too; not to mention the coping ability, interests and the mental status examination of the client. The initial phase of any assessment is to identify the patient. The identification of a patient incorporates the patient's name, sexual orientation, birth date or age, marital status, race or ethnicity, and language was spoken (Grohol, 2015, June 17). The client, Eliza, is an 18 years old, Caucasian female student at City University. At the first session, the client was provided with an intake document to complete. The client provided limited information. From the information she did provide, she revealed that she is experiencing anxiety and or stress and has low self-esteem. She disclosed that she has an okay relationship with her mother Joan who is an elementary school teacher and that she has a good relationship with her father Burt who is a truck driver. The client is not in treatment voluntarily. In order to complete the psychosocial assessment, this counselor requested that the client complete the Level-01Cross-Cutting Measure (CCM-1). The CCM-1 will be used as an initial screening tool to later assist this counselor in identifying symptoms in (a) specific diagnosis(s). The completed CCM-1 showed that the client is experiencing mild anxiety and should complete, DSM-5 Level 2 Cross-Cutting Symptom Measure-LEVEL 2-ANXIETY-Adult (PROMIS Emotional DistressAnxiety-Short Form) (American Psychiatric Association, 2016). To assist in completing the assessment this counselor would request that both parents complete the Personality Inventory for DSM-5-Informant Form (PID-5_IRF)-Adult (American Psychiatric Association & American Psychiatric Association, 2013). Due to the client’s reluctance providing information, and not attending treatment voluntarily, this counselor believes the information provided would be beneficial in creating a clearer understanding of the client and her presenting issues. At the completion of this psychosocial, the client’s presenting problem will be determined, second, the counselor and the client will decide what the achievable goals will be, Eliza 4 next, the treatment methods and intervention will be discussed and selected, and finally, how the client’s changes and success will be measured will be determined, whether by self-reporting or counselor evaluation. Part 2: Biopsychosocial Assessment Eliza is an 18-year-old, single, Caucasian female, referred to treatment by her college, City University, as the result of being caught drinking alcohol with her friends in the dorm by the RA. Eliza states’ she was just “buzzed” and did it because her friends believed “it was no big deal.” Eliza is of average height and slim build. She was dressed appropriately for her age, blue jeans, and a t-shirt. The client wore clothes that were too big for her. She later commented that she preferred bigger clothes because she did not like people looking at her. Her grooming and hygiene were adequate (Benet, 2014). She did not wear any makeup and her medium-length, brown hair was brushed into a ponytail. She sat in the chair in the corner of the room rather than the chair closer to the counselor. The client reported her mood as “fine.” She appeared to be alert and oriented. She was calm and cooperative although she stated she was not in treatment voluntarily. The client has difficulty maintaining eye contact. The client looks at her hands or on the floor. She reported low energy and fatigue (Schwitzer and Rubin, 2015). The client stated school as one of her stressors in life. She revealed, “Things came easily to me in high school, I just figured it would be the same in college.” She avoids class group projects as much as possible unless her professors require her to do so. She does not participate in any other school activities. The client stated her classmates or friends use her room for parties and often ask her to do their homework. She commented that she does not “hang out” with them other than when they come to her room. Eliza 5 The client has a strained relationship with her parents. She is the only child and feels she has become “the middle man” at home. This has created strained relationships for her with both of her parents. She keeps minimal contact with them, about once a week. She also stated that she has had trouble making friends. The client revealed the few friends she did have growing up moved away. Suicide/Homicidal The client denies any suicidal or homicidal ideations, past or present. She denies being the victim of any abuse but admits to being teased when she was in high school. Substance Use/Abuse The client denies and substance or alcohol abuse. She does admit to experimenting with marijuana but did not enjoy the experience. She also stated that she first tried alcohol in high school because her “friends asked me to drink it with them.” The client denies excessive drinking. The client denies blackouts or experiencing symptoms from a hangover. Addictions (gaming, gambling, pornographic) The client claims she only plays Massive Multiplayer Online “one or two times a week, three to five hours at a time.” She reluctantly admitted this takes its toll on her current issue with her grades. When further questioned about her online use, she stated that it helps her when she “is stressed out.” She admitted that her spending has increased and is now spending her allotted weekly food allowance playing online. She claims the thought of stopping just makes her more anxious. Diagnosis Eliza 6 301.82 (F60.6) Avoidant Personality Disorder 312.31 ((F63.0) Mild Gambling Disorder. Treatment Goals The goals for Eliza’s treatment are to assist her in relieving symptoms of her anxiety and to manage or alleviate urges to gamble. Plan Weekly Therapy 301.82 -Psychotherapy-would best benefit long term-short term would focus on immediate issues such as personal relationships and avoidance of stressful situations. -coping skills to manage stress -to learn more effective social skills and behaviors -examine and find closure for conflicts past and current -CBT--learn to identify maladaptive thought processes and replace them with adaptive thought processes 312.31 -CBT-to identify the thought processes that have led to gambling -learn coping skills to manage thoughts and urges to prevent gambling Eliza 7 Weekly Group Therapy -Gambling Addiction-gambling recovery Family Therapy 2-x month -to define parent-child roles -begin a healing process Part 3: Treatment Planning The DSM-5 Level 2 Cross-Cutting Symptom Measure-LEVEL 2-ANXIETY-Adult (PROMIS Emotional Distress-Anxiety-Short Form) has been determined to be the most appropriate for the client to complete. This is a result of the client completing the CCM-1, with the result of MILD ANXIETY. The client will complete this CCM-2 at regular intervals, once a month, to track the client’s symptoms (American Psychiatric Association, 2016). The Hamilton Anxiety Rating Scale (HAM-A) will be administered to monitor the effectiveness of the client’s treatment. Throughout treatment, this scale will assist the counselor to measure the severity of the client’s anxiety. The value of the HAM-A is to assess the client’s response to treatment starting in the first session. Part 4: Referral I am referring Eliza for behavioral therapy, which will determine what contributes to her changes towards self-destruction and some unhealthy behaviors. The patient who is a student currently drinks alcohol, avoids class group project, she has a strained relationship with her parents and she has trouble in making friends (American Psychiatric Association and American Psychiatric Association, 2013). I have supervised several of her Biopsychosocial treatment Eliza 8 programs. None of these have resulted in any behavior change. As a result of this persistent outrageous self-behaviors and conduct, her conditions are becoming more difficult to manage. These conditions are as follows: Personality disorder and gambling disorder. Behavioral therapy will make these conditions easier to manage. Since non-behavioral therapy programs have failed to provide any long-term benefits for the patient, I feel behavioral therapy is her only option. I hope behavioral counselor will find Eliza a suitable candidate for the behavioral program. It will provide a tool to assist her in focus on the personal responsibility of learning in school, as well as interacting with fellow students in class and parents at home. I anticipate that this will provide her with a significantly improved quality of life. Eliza 9 References American Psychiatric Association. (2016). Online Assessment Measures | psychiatry.org. Retrieved from https://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/onlineassessment-measures American Psychiatric Association, & American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association. Benet, PhD, PsyD, W. (2014). Personality Assessment Inventory. Retrieved from http://cps.nova.edu/~cpphelp/PAI.html Grohol, J. (2015, June 17). Avoidant Personality Disorder Treatment | Psych Central. Retrieved from http://psychcentral.com/disorders/avoidant-personality-disorder-treatment/ PsychGuides. (2016). Treating Problem Gambling and Gambling Addictions. Retrieved from http://www.psychguides.com/guides/gambling-addiction-treatment-program-options/ Schwitzer, A. M., & Rubin, L. C. (2015). Diagnosis & treatment planning skills: A popular culture casebook approach (2nd ed.). Thousand Oaks, CA: Sage Publishing.
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Explanation & Answer

Running head: ELIZA TREATMENT

Eliza Treatment Plan
Student’s Name
School affiliation
Date

ELIZA TREATMENT

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Eliza's answers on the consumption documents require a close and keen exploration.
Probably, are her feeling the reason for her stress? Has she ever experienced such feeling and
stress before joining college? These are the questions that I would ask to gain insight of her
therapy. A discussion on what she is feeling is significant as it will help her overcome her low
self-esteem. It is important to know if the low esteem existed before joining college or it is a
feeling that she developed while joining college. As a therapist, an explanation of what she feels
and the nature of the relationship will improve the process. I would like to know if she is
upholding here relationships with friends from previous classes and how often she visits her
parents (PsychGuides, 2016). It is also important to know if she has an interest in joining an
association, society, or club on campus. Engaging in co-curriculum activities is a good means of
meeting new people with same benefits. Also, the reasons as to why she chooses a different
college form her friends and if she had considerations of joining a different college that is maybe
closer at home is another consideration. The answers that she will give will determine what type
of therapy that will be successful with her (Schwitzer & Rubin, 2015).
Eliza’s Level 1 Cross-Cutting Measure contains useful information that can be key in
inquiring on things that she lost interest in and what proceeded that loss of pleasure or interest. I
will ask what was the situation that leads to her anxiety and if the condition has ever occurred
before. Knowing the steps, she is taking to deal with anxiety that is different from situations that
make her anxious. Eliza's aloof nature is unusual for people of her age; I would like to know her
life experiences as well. This investigation is worth to know how long she has felt this way. Her
feeling is a stem to others and her relationship with her parents hence, need for further
discussion. I would like to know of her experiences with her friend in high school hence their
presence is important for the therapy process. Her social relationship may have coupled her self-

ELIZA TREATMENT

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esteem problems, and this could be the reason as to why she has no close friends, and she is
trying to move with peers.
Eliza has re-counted that she ...


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