Sample assessment and treatment plan

Case Study Treatment Plan: The Assessment Process

THE ASSIGNMENT:

Case Study Treatment Plan: The Assessment Process
Resources
Website icon Case Study Treatment Plan: The Assessment Process Scoring Guide.
Website icon APA Style and Format.
Website icon Turnitin.
Website icon Writing Feedback Tool.
MS Word icon Case Study Treatment Plan Template.
Scoring Guide icon Case Study Treatment Plan | Transcript
For this assignment, complete the Assessment Process sections of the treatment plan for your course project. This treatment plan is based on the case study you selected for your course project. You can review the case studies in the Case Study Treatment Plan media piece available in the resources.

The Assessment Process sections of the treatment plan that you will complete for this assignment consist of the following:

Identifying information.
Presenting problem.
Previous treatments.
Strengths, weaknesses, and social support systems.
Assessment.
Diagnosis.
References.
The sections of the treatment plan you submit for this assignment should be 4–5 pages in length, with a minimum of two references from current articles in the professional literature in counseling. Be sure to cite your references in current APA format.

To assist you in completing this assignment, please use the Case Study Treatment Plan Template (available in the resources) to organize your work. Each section of the template includes a description of the type of information you must include. You should type your paper directly into this template, save it as a Word document with your name, and then submit it to the assignment area.

For additional information, see the course project description.

Submit your paper to Turnitin before you post it to the assignment area so you can catch any areas that are showing up as possible plagiarism.

Note: Your instructor may also use the Writing Feedback Tool to provide feedback on your writing. In the tool, click on the linked resources for helpful writing information.

THE CASE STUDY

Oscar is a 19-year-old Hispanic male who is the oldest of 5 children. His family has been farming the same land for 4 generations. Currently they grow vegetables for the regional grocery chain's produce departments. They live in a rural area of the county. Three generations live in two separate houses on their land. They are fiercely independent and have little to do with people in town, although the family itself is extremely close knit.

Oscar is currently a freshman at the same college his father attended, majoring in agriculture. When he came home for spring break, his parents noticed significant changes in his appearance. He had lost weight, looked haggard, wasn't sleeping and seemed irritable and argumentative. He told his parents that he did not want to return to college after the break. He went on to say that his roommate had placed cameras in the room so he could record everything Oscar did while the roommate was absent. His grades were poor and he expressed that he believed his instructors were prejudiced against him. This poor performance was in stark contrast to his performance in high school, where he was in the top 10% of his class. Within days of coming home he had stopped showering and began wearing multiple layers of clothes (3 pairs of jeans and 4 t-shirts). He became essentially non-communicative, responding to questions with one-word answers and not initiating conversation. Oscar seemed unhappy or irritable whenever he encountered a member of his family and began spending all his time in his room. He even refused to talk with his youngest brother, with whom he had always been close. He did not take meals with his family, a long-standing tradition in his family, and left his room only in the middle of the night. He could then be heard opening drawers in the kitchen, going into his siblings' rooms and leaving the house for long periods of time.

The family (parents and grandparents) became very disturbed and consulted their priest. The priest recommended that the parents take Oscar to see a fellow parishioner who is also a counselor. This counselor was also disturbed with Oscar's presentation and recommended hospitalization. The family was very reluctant, but eventually agreed. By the time they got to the hospital, Oscar was essentially non-communicative, only nodding or shaking his head in response to direct questions.

The parents provided history that indicated Oscar had been a good student in high school and had participated in the school's FFA club. He has always wanted to carry on the family tradition of farming. He did not have many friends, but the family attributed that to their living in the country.

The psychiatrist diagnosed Oscar with major depressive disorder, single episode, severe with psychotic features and prescribed anti-depressants. He was released three weeks later, with some improvement. One week later he was readmitted, with the same presentation he had at the previous admission. This time, though, his father reported that he had found a cache of knives in the barn, some from the house, some from the grandparent's house and some from the barn itself. When he asked Oscar about them, Oscar responded that he needed them to protect himself from attacks. When his father asked from whom, Oscar responded that he had seen one of his college professors in the field of broccoli. That same day, Oscar's mother found notes stuffed between Oscar's mattress and box springs in Oscar's handwriting. The content of them was Oscar arguing with someone about killing his younger siblings. One side did not want to do it and begged to not have to; the other side ordered the killings, saying that was the only way to keep them safe. In light of these two events, both parents were afraid for Oscar to remain at the house. Oscar swore that he would never hurt any of his family and said that was why he had been keeping away from them. His parents could not be sure that no harm would come and were unable to watch Oscar day and night. Therefore, they readmitted him to the hospital.

During this admission, Oscar was more forthcoming with his treatment team. Once they had this additional information, the team realized that Oscar's initial diagnosis had been wrong. They began a re-assessment. Oscar acknowledged that the problems began about the time of the new semester. He was unable to complete his school work, as he was "consumed" with the need to follow instructions that were being given to him. These instructions actually began with a buzzing in his head, which quickly evolved into specific directions. When pressed, he acknowledged that he did not know who was giving him the directions, though he sometimes thought it might be Jesus. These instructions were for him to keep a log of every time he heard a door close on his hallway in the dorm. Oscar came to believe that doing this was the only way to keep his family safe from dark angels. Oscar tried to keep these voices quiet by smoking marijuana on a daily basis. While this helped in the short term, it also made it more difficult for him to complete any of his school work. By the time for spring break, the messages had begun to change. He was no longer able to keep his family safe by keeping a list; the voices told him he would have to kill them. Oscar knew that he did not want to kill his family. He could also not avoid going home for spring break. Therefore, he devised the plan to isolate himself.

Once the family recovered from their initial shock and as Oscar began to show some improvement with his new, anti-psychotic, medication, his parents and grandparents wanted to take him home to the farm. They believed that life on the farm, being outside and with hard, physical labor would cure Oscar. Finally, Oscar agreed to tell them what has been happening with him. At that point, the family agreed to residential treatment for Oscar. When asked if anyone else in the family has ever had symptoms like this, the grandfather acknowledged that he had a brother (Oscar's uncle) who had religious visions. This brother left the family and became a monk. Later the family heard that he had died under mysterious circumstances. One of the other monks at the monastery told Oscar's grandfather that his brother had died from engaging in a prolonged fast. The family is very lucky on two counts: 1) they have their medical insurance through the farmer's co-op and it includes coverage for residential treatment for up to a year, and 2) this hospital has a residential treatment unit for late adolescents and young adults. You are working as a counselor at the Residential Treatment facility where Oscar has been placed. He will be here for a minimum of 6 months and as long as one year. Professional staff at this facility includes 3 counselors, an addictions counselor, a social worker (currently on maternity leave), a psychologist, and 2 nurses on every shift. Oscar's psychiatrist is also on staff and will continue to follow his care.

The social worker usually coordinates clients' treatment plans; however she is currently away on maternity leave so you will be the lead therapist who is coordinating Oscar's treatment during the next 45 days. Once she returns, you will collaborate with her for developing Oscar's post-residential treatment and resources for him and his family.

COUN6331 CASE STUDY TREATMENT PLAN
Instructions: Please type directly into this template as you develop your Treatment Plan. Your submitted assignments in Unit 5 and Unit 9 must be completed within this template in order for you to receive credit for your paper.

Unit 5 Assignment: Complete the first six sections of the template, plus your reference list, for the Unit 5 assignment. After you have completed the final draft of these sections, save the template as a Word document with your name (for example, Smith Unit 5 assignment) and submit it to the courseroom assignment area by the deadline for the Unit 5 assignment.

Unit 9 Assignment: Complete the last five sections of the template, plus your reference list, for the Unit 9 assignment. Although your instructor will only be reviewing the last five sections to score your paper for Unit 9, please retain the information you have already written in the first sections within the template so your instructor can refer back to this when reading your Unit 9 assignment. When the full template is completed, save it as a Word document with your name (for example, Smith Unit 9 assignment) and submit it to the courseroom assignment area by the deadline for the Unit 9 assignment.

Case Study Treatment Plan

Your Name

COUN6331

Mental Health Counseling Clinical Internship 1

Case Study Treatment Plan

Unit 5 assignment sections: The Assessment Process (4–5 pages plus references)

Section 1: Identifying Information

Describe the client in your own words. Include demographic data and relevant context (living situation, employment, current functioning, et cetera). Your description should be concise.

Section 2: Presenting Problem

Describe the key concerns that have brought the client to counseling at this time. Include a brief description of any relevant history (for example., previous incidents of concern, length of time issues have been going on, prior trauma, or other critical events related to the presenting problems).

Section 3: Previous Treatments

Summarize the client’s previous experience in therapy. Include hospitalizations as well as any community resources or other medical/mental health services the client has used. Include the degree to which previous treatments were successful; has the client had any experiences with previous treatments that may have a negative impact on the current counseling process?

Section 4: Strengths, Weaknesses, and Support Systems

· Describe the client’s areas of strength and resilience.

· Describe the client’s limitations, challenges, or areas in which the client lacks knowledge, awareness, or specific skills.

· List the support systems the client currently has access to, such as family, friends, community groups, et cetera, and the extent to which the client is currently able to utilize these supports.

· Describe the impact of a co-occurring substance use disorder on the client’s medical and psychological disorder.

· Identify the key factors that may impact this client’s successful progress in therapy, how and why these factors may have an impact on treatment success, and how you will take these factors into account as you develop your treatment plan.

Section 5: Assessment

Describe the process you will use to complete a clinical assessment of this client. If you intend to use specific instruments (such as self-report instruments, structured interviews, or psychological tests), state what they are and why you have selected them. Discuss any concerns you will need to address regarding the relevance and biases of assessment tools with multicultural populations. Also discuss the methods you will use to arrive at an accurate DSM diagnosis for this client.

Section 6: Diagnosis

Present a DSM-5 diagnosis for the client. Provide a description of your rationale for making this diagnosis (for example, what information did you consider?). Discuss other possible diagnoses that you ruled out (or will need to rule out once you have additional information).

References for Unit 5 Assignment

Support your decisions and ideas for the Unit 5 assignment with a minimum of two references to articles from current professional journals in the field of counseling. Use correct APA format.

Unit 9 assignment sections: Treatment Goals (4–6 pages plus references)

Section 1: Treatment Plan Literature Review

Review the current research and best practices presented in the professional literature that relate to types of clients and presenting issues that are similar to the case you have selected. What does the literature have to say about the most effective types of counseling approaches used with clients who share similar social-cultural backgrounds, history, current situations, and/or presenting problems? Be sure to address the impact of diversity when selecting approaches and interventions. Summarize your review of the literature so it provides clear support for your choice of counseling approach, goals, and interventions that you will be presenting in the sections below. Keep direct quotes to a minimum; you should paraphrase the information you’ve reviewed in your own words. Remember to use correct APA format for all citations.

Section 2: Goals and Interventions

List four goals that you will work on with this client during the first 3 months of counseling. Present these goals in concrete and specific terms. For each goal, list two specific interventions that you will use during counseling sessions to assist the client in making progress towards the goal. What will let you know if these interventions are effective (for example, what changes would you expect to see in the client during sessions; what changes between sessions might the client report; will you utilize any self-report measures or other assessment instruments to help measure change)? Be sure your interventions reflect the effective practices that you described in your treatment plan literature review; address how your approaches will also take the client’s sociocultural background into account and their appropriateness for addressing addiction and co-occurring disorders.

Section 3: Communication With Other Professionals

Who will you consult with as you develop your client’s treatment plan and begin to work with him or her in therapy (for this segment, assume that you have a written consent from the client to do so)? This might include other medical/mental health professionals currently working with the client, as well as previous therapists; it could also include experts in the field with whom you may want to consult about the client’s presenting issues. How will this information inform your work with the client?

Section 4: Medications

Discuss in the section any medications your client is currently taking. What impact do these medications have on the client (for example, side-effects, improvement in symptoms, interactions with other drugs, et cetera)? What information do you want to provide to the client about these medications and how might you need to continue addressing the issue of medication in your work with this client over time? Do you think psychopharmacological medications are advisable for this client? Would you consider referring this client to appropriate medical professionals for evaluation for psychopharmacological medications?

Section 5: Legal, Ethical, and Other Considerations

How will the ACA Ethical Standards apply to your work with this client? Describe any potential legal or ethical issues that may arise and how you will address them. Refer to the specific state laws or regulations or ethical standards in your discussion. Also list any other red flag issues that you have identified and the ways in which you address these issues with the client.

References for Unit 9 Assignment

Support your decisions and ideas for the Unit 9 assignment with a minimum of four references from current professional journals in the field of counseling. Use correct APA format.

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