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
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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
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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,
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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.
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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
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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
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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
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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.
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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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