Assessment and Treatment Plan - Case Study Example

Assessment and Treatment Plan Assessment and Treatment Plan Initial Assessment Mental Status Check of Client: Julia Date: Appearance:__Well groomed __Neat __Casual _√_Unkempt __Unclean __Inappropriate __Bizarre __UnusualGeneral Presentation:__Cooperative _√_Guarded __Distractible __AgitatedSpeech:__Clear __Tone (loud/soft) __Rhythmic _√_Poverty of Speech __Rapid __Slow __Stutter __Pressured __SlurredAffect:__Appropriate __Blunted __Melancholy _√_Restricted __Labile __Inappropriate __FlatMood:__Even __Depressed/sad _√_Anxious _√_Irritable __Angry __Elevated __Euphoric/elated __Expansive __Passive __Pessimistic __BluntedOrientation:_√_Time _√_Place _√_PersonIntelligence Level:__High _√_Average __Low __RetardedJudgement:__Rational __Impaired __Immature _√_ImpulsiveInsight:__Emotional __Intellectual __Denial __Blames Others _√_Blames Self __Slight Awareness _√_ Acknowledges problem Thought Content:__Logical/Reality Based __Delusions __Obsessions __Tangential __Illogical __Loose Associations __Hallucinations __Ideas of reference/influence __Compulsions __Flight of Ideas _√_Circumstantial __Inhibited __Concrete __AbstractComments: Patient displays all symptoms of moderate substance addiction’RISK STATUS CHECKViolence/Abuse: (Domestic and Workplace, Child and Sexual)Present Risk: ____None ____Low __√__Moderate ____HighCurrent: physical confrontation with sexual partner and parentsPast: Conflicts with friends parents and partnersSuicide/Homicide: (Past attempts, Prior inpatient admissions, Ideation, Intent, Attempt, Plan, Compromised ADL’s)Present Risk: ____None ____Low _√___Moderate ____HighCurrent: no immediate risk of suicidal thoughts or plansPast: two suicidal attemptsOther risks: (eating disorder, history of multiple diagnoses, non-compliance with earlier treatment, runaway): substance addiction and relianceSymptoms: Weight gain/loss Sleep decreased/increased Concentration increased/diminished Interest level decreased FearRestlessness Increased arousal Racing thoughts Irritability Avoidance Hopelessness CLIENT RESOURCESStrengths identified by client: willingness to advocate, associates with self as opposed to a group, identifies problemAdditional client strengths seen by clinician: physical and mental awareness Family members/others who will be supportive of client in treatment: motherFamily member/support people to have involved in treatment : noneCLINICAL ASSESSMENT/DIAGNOSTIC SUMMARY(Evaluate, integrate and summarize the following information: Background, medical, social, presenting problem, signs & symptoms and impairments.

Tie these in with the patient’s strengths and needs. Integration of data is more important than specific details.)Julia, an unwed, unemployed and substance addicted mother lives with her irritable parents, who have custody over her child. Her addiction is traceable to her teenage years, after which she occasionally engaged in substance abuse. She suffers panic attacks and has engaged in some criminal activity, though has not been jailed. The patient has control of her mental faculties, makes judgments averagely, and is able to rationalize and establish the source of her problem.

Current friends are detrimental to her treatment as they engage in substance abuse as well. DIAGNOSISAxis I panic disorderAxis II none Axis III noneAxis IV patient is currently living with hostile parents, unemployed, substance addictionAxis V Current GAF: 15 Highest past year: 9PROGNOSIS____Excellent ____Good ____Fair __√___Guarded ____PoorComment: Patient is secretive and believes she is hopeless, though exhibiting self-restraint traits, She acknowledges reliance her substance addiction.

She believes her current addiction comes out of necessity. Treatment PlanPsychological theory and explanation of fit (humanistic, behavioral, psychodynamic, cognitive, social-learning, self theories):The patient indicates all signs of Substance-use disorder. She exhibits dependence on and abuse of alcohol and drugs, and seems not to function without using the substances. In addition, the patient exhibits symptoms of anxiety disorder, which is associated with substance abuse or possible childhood fears.

Therapy Choice and Treatment Strategy:Psychological psychodynamic and behavioral treatment strategies are recommendable for this patient. Her irritability and conflicts with friends and parents need intervention (Seligman, 2006). The [patient has a low self-esteem and has little self-worth, behavioral therapy shall address this issue. What she needs most is encouragement, thus positive reinforcement treatment strategy is to be used. This is needed to improve the view on self and instill belief of capability in her (Marks-tarlow, 2012).

Particular Goals and Objectives (interventions) for client: 1. Reduce dependency on drugsa. Minimize dependence on hard drugsb. Eradicate dependence on alcohol and cigarettes. 2. Improve self-esteem and behaviora. Encourage independenceb. Encourage socialization skills 3. Alter behavior trends a. Encourage proper friend choicesb. Instill accountability Summary:Julia is in this condition because of wrong choices that led to her addiction to drugs. The patient suffers no medical conditions that might have caused her to take on substance abuse, but other environmental; factors such as peer influence could have easily caused her addiction (Maars, 2011).

The treatment plan chosen is the best choice since the patient displays strong metal and personal awareness capabilities, she recognizes the effect the drugs has on her and this treatment shall appeal to her self-awareness and acknowledgement. This plan may be criticized for relying on the patient for the recovery as opposed to instilling it (Yalom & Leszcz, 2005). ReferencesMaars, J. V. (eds). (2011). Alcohol Dependence and Addiction. New York: Nova SciencePublishers.Marks-tarlow, T. (2012).

Clinical Intuition in Psychotherapy: The Neurobiology of EmbodiedResponse (Norton Series on Interpersonal Neurobiology). New York: W. W. Norton & Company. Seligman, Martin, E. P. (2006). Learned Optimism: How to Change Your Mind and Your Life.New York: Vintage Yalom, I. D., & Leszcz, M. (2005). Theory and Practice of Group Psychotherapy (5th ed.). NewYork: Basic Books.