Would You Have Documented Anything Differently? Why Or Why Not?

In Topic 4, you created a treatment plan for your client. Create a SOAP note that would go in the client’s chart following the visit. Post the SOAP note as a reply to this discussion thread. For follow-up discussion, evaluate at least two of your peers’ SOAP notes. Would you have documented anything differently? Why or why not?

Min 150 with at least 1 in-text citation

Running head: TREATMENT PLAN 1

TREATMENT PLAN 7

 

 

 

 

Eliza Case Study: Treatment Plan

Student’s Name

Institutional Affiliation

Course Title

Instructor’s Name

Due Date

 

Eliza D. Case Study

Treatment Plan Development

Eliza Doolittle is an 18-year-old Caucasian female college freshman studying Engineering. He comes from a family with a history of successful engineering careers. She is good in academics, but experiences problems maintain her GPA due to demanding course loads. She has no family support symptoms and reports feelings of loneliness, low self-esteem, and stress. Eliza also faces peer pressure to engage in substance abuse and is addicted to non-academic activities such as gambling and video gaming. Her mental health is poor, and she needs treatment. Based on the information provided, Eliza suffers from psychosis mental disorder. Psychosis is characterized by severe impaired cognitive and neurologic functioning. According to DSM-5 criteria, psychosis occurs when individuals lose the sense of reality and develop negative emotions (Bastiaens and Galus, 2018). Psychosis results from various factors, including substance abuse and impaired cognitive development.

Problem Identification and Diagnostic Decision Making

The level 01 cross-cutting measure (CCM-1) can be used to develop suitable treatment interventions for Eliza. Eliza is an adult, and therefore the counselor would refer to DSM-5 CC level 1 to measure the presence and severity of symptoms. The CCM will identify problematic areas in Eliza’s life that could interfere with treatment interventions. The level 1 CCM will serve as a screening tool to help the therapist recognize and classify Eliza’s symptoms. The counselor can use the 23 questions to assess the psychosis, substance abuse, personality functioning, repetitive thoughts and behaviors, and suicidal ideation psychiatric domains. These questions will provide the counselor with more information about Eliza and help select the best treatment plan. Some of the questions include “do you feel frightened, anxious, or on edge,” “do you have thoughts of hurting yourself,” and “do you drink at least four alcoholic drinks in a day?” The results of CCM-1 indicate that Eliza was suffering from mild anxiety. Mild or greater scores indicate a reason for concern within the psychiatric disorders.

Theoretical Approach

Psychosis treatment embeds psychological therapies to relieve patients from psychosis symptoms and reduce relapse. Eliza’s psychotic symptoms result from interplay between predisposing bio psychosocial vulnerability and environmental stressors. Eliza has emotional difficulties such as low self-esteem and cognitive deficits. The stressors such as stressful school life, loneliness, and substance addiction affect Eliza’s mental and emotional processes leading to abnormal behaviors, depression, and cognitive processing difficulties. Negative interpretation of these experiences leads to changes in the self. Cognitive Behavioral Theory (CBT) I suitable for addressing Eliza’s stress and vulnerability factors and aid in the overall psychosis treatment. CBT is based on psychosis’s stress-vulnerability models and cognitive therapy of mental disorders. Psychosis experiences are integral to CBT in that the theory focuses on how individuals interpret their symptoms (Landa et al., 2016). CBT aims to help patients understand psychosis as less distressing and help they prevent reoccurrence and attain a satisfying quality of life. A therapist using the CBT approach focuses on the patient’s thoughts, perceptions, and images to develop a new understanding. According to Landa et al. (2016), the counselor reviews the evidence of these beliefs and evaluates them to identify biases that lead to mood and behavior changes. The therapist then encourages the patient to adopt new behaviors and thinking throughout the therapy sessions.

In the initial stages of intervention, a counselor using CBT engages the patient in a discovery journey. The therapist affirms and assures Eliza that her problems are taken seriously. At this stage, the CBT therapist ensures that he understands Eliza’s mental health, medical, legal, and substance abuse issues to attract patients’ involvement. This intervention explicitly relieves the patient from distress, enhances their confidence, and reengages them in treatment. The therapist formulates a list of goals to be achieved and seeks positive and negative feedback from the patient. A CBT therapist can treat mental health by engaging Eliza in improving self-esteem and reducing anxiety and worry. The therapist needs to manage Eliza’s delusions through empathetic exploration (Manusov et al., 2020). The therapists should use responses such as “It must be overwhelming for you to study the engineering course materials” to lower Eliza’s defensive stance for engaging in substance abuse. It would also be beneficial to highlight existing coping mechanisms used by Eliza to deals with the pressure for the past two weeks. Both Eliza and the therapist should identify vulnerabilities and early warning signs that lead to strange behaviors and substance abuse. Eliza noted that she engages in substance abuse due to peer pressure. The therapist should identify this vulnerability and equip Eliza with skills to cope with peer pressure and make independent decisions. According to Brooks, Chalder, and Rimes (2017), the therapist should rehearse these coping mechanisms and compensatory strategies to prevent relapse.

Another critical step is to discuss with Eliza how to monitor warning signs and how to overcome them. The therapist may suggest that Eliza be walking out of the dorm whenever her friends bring alcohol or move to the library to study during free time. When treating negative symptoms, the therapist should understand that he cannot push Eliza out of negative symptoms but may help her. The therapist should identify possible motivators that will help Eliza think positively. For example, Eliza has been scoring Bs in her academics, and the therapist can use this strength to encourage Eliza on her academic achievement. The therapists need to determine pressurizing course loads, set realistic goals, and help Eliza deal with setbacks. CBT approach aims at fostering active involvement, recognizing motivators, and striking a balance between acceptance and the need to change.

Progress Monitoring

Monitoring a client’s progress influences client outcomes through the therapist’s feedback and effect on clinician behavior. According to Jensen-Doss et al. (2018), monitoring a client’s progress and using feedback to make clinical decisions improve treatment outcomes. Monitoring Eliza’s treatment progress is essential in choosing what is best for her mental condition. The Level 02 Cross-Cutting Measure (CCM-2) suitable for future sessions is the disorder-specific severity measure. This tool will help the therapist to track Eliza’s treatment progress over time. The therapist will use the tool to determine the frequency of psychotic symptoms and severity across diagnoses.

An additional assessment tool that the therapist could use is the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) measures to monitor treatment progress (Park, Lee, and Choi, 2016). The therapist can use this assessment tool to rate the severity of psychotic disorders. CRDPSS measures eight psychotic symptoms, including negative symptoms, depression, mania, impaired cognition, delusions, hallucinations, disorganized thought, and abnormal psychomotor behavior. The items on the measure are scored on a five-point scale ranging from not present to severe. Symptoms severity indicates critical aspects of the illness as experienced by the patient in the past seven days. CDRPSS is appropriate in Eliza’s case study to assess the negative symptoms affecting her mental health. The assessment tool is administered during a clinical assessment to monitor the patient’s progress with treatment. The therapist rates symptom severity based on clinical judgment and patients’ response to treatment. He selects the level that accurately fits the seriousness of Eliza’s condition and indicates each item’s score. Results on each item are interpreted independently, and high scores indicate problematic areas which may warrant further treatment.

Assessments are essential only when the results are utilized effectively. Interpreting test results to clients produces positive outcomes. In the case scenario, communicating the assessment results would require the therapist to sign a consent form to keep Eliza’s relevant information and her diagnosis confidential (Oramas, 2017). Eliza is a young adult, and sharing her clinical information with third parties could negatively affect her self-esteem and confidence. Communicating the assessment result should align with Eliza’s preferences. The first step in communicating Eliza’s assessment results is to prepare her for the results. The therapist should emotionally prepare Eliza to accept the results and make the right decisions. Second, the therapist should present Eliza with the assessment results and ask for her opinion to know Eliza understands and interprets the results. Third, the counselor should communicate the assessment and interpret them to Eliza. According to Testa, Brown-Grant, and Bedford (2019), most clients prefer worded communications instead of written ones. The therapist should use an interactive approach whereby he shares the results with Eliza expertly and influentially. At this stage, the therapist helps Eliza clarify and explain what the results imply to her. Adverse reactions from Eliza mean that she is not happy with the results. Hence, the therapist should help her get through the unhappiness. Lastly, the therapist should encourage Eliza to accept the results and reaffirm her with positivity. Eliza’s family should receive the assessment findings only when Eliza consents to share private information. The therapist should keep the assessment personal and confidential.

To agree on a schedule, desired outcomes and strategies to achieve the treatment goals, both Eliza and the therapist should ensure openness, integrity, honesty in deciding what is best for Eliza. The therapist should prioritize Eliza’s social, academic, and quality of life needs. Eliza noted that she has academic pressures since she comes from a family of engineers. Thus, the therapist should secure academic and moral support to motivate Eliza to pursue her educational goals. It is also vital to recommend alternatives other than alcoholism to help Eliza overcome peer pressure and loneliness. These alternatives include joining an anti-alcoholic club or praying for divine intervention. The therapist should also do follow-ups to determine if the therapy was effective or successful. In case the therapist feels incompetent to offer adequate counseling, he should refer Eliza to a psychiatrist to improve the treatment outcomes. It is also ethical for a therapist to end treatment if a client refuses a referral to other therapists (Oramas, 2017). If Eliza refuses the referral, the therapist should discontinue the therapy.

 

 

 

 

 

 

 

References

Bastiaens, L., & Galus, J. (2018). The DSM-5 self-rated level 1 cross-cutting symptom measure as a screening tool. Psychiatric Quarterly89(1), 111-115.

Brooks, S. K., Chalder, T., & Rimes, K. A. (2017). Chronic fatigue syndrome: cognitive, behavioral and emotional processing vulnerability factors. Behavioural and cognitive psychotherapy45(2), 156-169.

Jensen-Doss, A., Haimes, E. M. B., Smith, A. M., Lyon, A. R., Lewis, C. C., Stanick, C. F., & Hawley, K. M. (2018). Monitoring treatment progress and providing feedback is viewed favorably but rarely used in practice. Administration and Policy in Mental Health and Mental Health Services Research45(1), 48-61.

Landa, Y., Mueser, K. T., Wyka, K. E., Shreck, E., Jespersen, R., Jacobs, M. A., … & Walkup, J. T. (2016). Development of a group and family‐based cognitive behavioural therapy program for youth at risk for psychosis. Early intervention in psychiatry10(6), 511-521.

Manusov, V., Stofleth, D., Harvey, J. A., & Crowley, J. P. (2020). Conditions and consequences of listening well for interpersonal relationships: Modeling active-empathic listening, social-emotional skills, trait mindfulness, and relational quality. International Journal of Listening34(2), 110-126.

Oramas, J. E. (2017). Counseling ethics: Overview of challenges, responsibilities and recommended practices. Journal of Multidisciplinary Research9(3), 47-58.

Park, S. C., Lee, K. U., & Choi, J. (2016). Factor structure of the clinician-rated dimensions of psychosis symptom severity in patients with schizophrenia. Psychiatry investigation13(2), 253-254.

Testa, D., Brown-Grant, J., & Bedford, D. (2019). Communicating Assessment Results. In Assessment Strategies for Knowledge Organizations. Emerald Publishing Limited.