Benchmark – Initial Treatment Plan: Eliza
Benchmark – Initial Treatment Plan: Eliza
A psychosocial assessment involves a comprehensive evaluation of an individual’s mental, physical, and emotional health, which is used to identify any underlying health issues where treatment can be effected. This enables therapists to perform accurate diagnosis as well as develop effective treatment plans (Schwitzer ; Rubin, 2015). Based on the information collected about Eliza who is the client, the client is an 18-year-old Caucasian female and a first year student in college undertaking an engineering course. The client has some health problems which have negatively affected her in school after being caught in the school dormitory with alcohol which led to her being recommended for counseling since the school is an alcohol-free campus. This paper will analyze the initial treatment plan for the client.
Part 1: Intake
During her first session, the client was issued with an intake document to complete which included her personal information and the reason why she had sought counseling services from the facility. The client gave out inconclusive information, which is not satisfying to make an accurate diagnosis and implement an effective treatment plan (Schwitzer ; Rubin, 2015). Information collected from the intake document revealed that the client had issues with her self-esteem and that she has been having anxiety and stress. The client is also not willing to get medical assistance as indicated in her response of the reason for seeking counseling services. The client did not provide any life stressors and is not currently on any drugs for mental health. To access more information about the client, the therapist should provide the client with a CCM-1 document to ensure an effective biopsychosocial assessment on the client (American Psychiatric Association, 2017).
Information in the CCM-1 form would be used in screening to identify specific symptoms and make accurate diagnosis. Information provided by the CCM-1 form can also be used to guide clinical decision-making in the diagnosis process. The therapist can proceed to identify additional areas of inquiry, which may include determination of the severity of anxiety as indicated in the CCM- 1 form (American Psychiatric Association, 2017). After the client completed the Cross-Cutting Measure, there was evidence of the client experiencing mild anxiety, which could persist for several days. Since the client is reluctant to provide more information as she is not attending the counseling session voluntarily, the DSM-5 Level 2 – Anxiety – Adult form can be administered to help in providing more information about the client’s health status and help in determining any other underlying issues (American Psychiatric Association, 2017).
The therapist should provide the client with DSM-5 Level 2 – Anxiety – Adult form where the parents of the client can be involved in completing the form. This is because the client is hesitant in providing information and sufficiently filling the forms. The therapist can analyze the scores, which are used to indicate the severity of anxiety and guide the therapist in making decisions related to the treatment plan (American Psychiatric Association, 2017). At the end of the biopsychosocial assessment for Eliza, some of the questions that would need to be answered include what health issues are affecting Eliza and to what extent has these issues impacted the client. Determining the underlying issues will enable the therapist to determine the healthcare goals to be achieved at the end of the treatment session. This is important in helping the therapist in developing an effective treatment plan (American Psychiatric Association, 2017).
Part 2: Biopsychosocial Assessment
From the information collected from the completed biopsychosial assessment for Eliza, it is evident that the client has anxiety and low esteem issues, which have led to the problems which she is currently experiencing (Brown & Barlow, 2014). From the intake document, Eliza checked these symptoms on the presenting problems list. She also checked the same problems on the CCM-1 form where she checked mild anxiety an indication of the underlying issue. Other problems had low scores with anxiety been present for several days (Brown & Barlow, 2014). On the biological aspect of the biopsychosocial assessment, the client denied having any drinking issues and being addicted to any drugs. The client is also not under any medications for mental health. On the psychological aspect, the client denies seeing a therapist before or had any counseling in the past. The client also denies having suicidal thoughts. However, the client indicates having issues in being close to other people and having sleeping problems (Brown & Barlow, 2014).
On the social aspect, the client’s parents have a good relationship and no life stressors affecting the client as indicted in the intake document. However, the client expresses struggles in making friends in college with most of her drinking occasions being because of influence from her friends (Brown ; Barlow, 2014). Some of the symptoms present in the client include influence from other friends to indulge in alcohol with the client also being stressed by school due to the increased study requirements. The client also struggles to make friends in school although she denies being lonely (Brown ; Barlow, 2014). Eliza has experiences of teasing in high school, which she denies to discuss the specifics. These symptoms indicate anxiety disorder as there is no adequate stimuli to cause anxiety for the client. The DSM-5 diagnostic criteria for anxiety involve excessive anxiety and worry which may occur in many days and difficulty in controlling the anxiety (Brown ; Barlow, 2014).
In the assessment of the client’s symptoms, Eliza indicated a score of 2 in avoiding situations which make her anxious an indication that she has a difficult time in controlling her anxiety (Brown & Barlow, 2014). This has also affected her in making friends in college as well as giving in to influence from other friends to indulge in alcohol. The ICD-10 diagnostic criteria involve a period of at least 6 months where a client has continuous tension and worry about every day events with other symptoms being present (Brown & Barlow, 2014). The client has a fear of losing control of her anxiety, which makes her to avoid situations, which make her anxious. The client has also problems with her sleeping patterns and feelings of hopelessness. This has resulted to the client in not having close friends at the school. These symptoms are attributed to anxiety disorder using the ICD diagnosis (Brown & Barlow, 2014).
Initial treatment goals and plan will include helping Eliza in addressing some of the symptoms of anxiety as well as alleviate her addiction to online video gaming. It is important for Eliza to manage the influence from her friends to indulge in alcohol, which may lead to negative effects on her health (Okazaki, Kassem, & Tu, 2014). It is also important to help Eliza in managing stress, which is evident from the information collected from the CSM 1 form. The treatment plan may involve weekly therapy, as this would help the client in addressing the short-term as well as the long-term issues, which may be attributed to the anxiety disorder (Okazaki, Kassem, & Tu, 2014). Psychotherapy will also help the client in improving her relationships with other individuals as well as make a group of supportive friends, which are important in providing assistance in different times. This will include the development of social skills (Okazaki, Kassem, & Tu, 2014).
Part 3: Treatment Planning
Based on the information provided, the level 02 Cross-Cutting Measure (CCM-2) that I would utilize in future sessions is the Level 2-Anxiety-Adult (PROMIS Emotional Distress-Anxiety-Short Form (American Psychiatric Association, 2017). This level 02 Cross-Cutting Measure measures 7 items that are used to assess anxiety in adult individuals from the age of 18. This form is completed by the client as well as an informant and is important in helping therapists to rate the severity of an individual’s anxiety (American Psychiatric Association, 2017). This measure gives different scores to the different items from 1 to 5 which are summed up to give a total score. The clinician also reviews the scores during the interview, which are also added together to give a total score of the client. This is then used to calculate the severity of the disorder (American Psychiatric Association, 2017).
This measure is beneficial in that is indicates specific areas which may need further assessment and provides important information which guides the decision-making process of the clinician (American Psychiatric Association, 2017). An additional assessment outside of those provided by the APA that would measure what the future counselor is attempting to assess based on the treatment goals/plan is the Hospital Anxiety and Depression Scale (Okazaki, Kassem, ; Tu, 2014). This tool was developed by Zigmond and Snaith to determine the severity of anxiety and depression. The Hospital Anxiety and Depression Scale has fourteen items with 7 of the items relating to anxiety while the other 7 relate to depression. Each item has a score from 0 to 3 where a total of the scores is calculated to determine the level of anxiety or depression (Okazaki, Kassem, ; Tu, 2014).
Conveying the assessment findings to the client and family is an important process, which may negatively impact the parties if done ineffectively. This requires that clinicians use the most effective methods to pass this information (Okazaki, Kassem, ; Tu, 2014). One of the ways to convey these findings is helping the client to understand the role of these assessments. The most important aspect in assessments is helping the clients to understand the process and what impact this has on their health status (Okazaki, Kassem, ; Tu, 2014). Clinicians can focus on the strengths of the family as well any coping capacity, which play an important role in understanding the findings of the assessment. Clinicians can also be sensitive and respectful without being judgmental to clients as well as other family members, which will create mutual trust between the client and the clinician (Okazaki, Kassem, ; Tu, 2014).
Prioritizing the needs of the client can be done by analyzing any immediate concerns, which may worsen the situation. Addressing these needs is also important in preventing the clients from developing other health issues. The first step in addressing the needs of patients is by determining the symptoms, which are serious and require immediate action (Brown ; Barlow, 2014). Agreed upon outcomes, measures, and strategies can be formulated by collaborating with the family members who will provide more information and support the client in achieving set healthcare goals. Evidence-based information may be used to determine effective measures and strategies to implement to achieve the desired goals (Brown ; Barlow, 2014).
Part 4: Referral
Possible referrals to make with the client include other qualified psychiatrists who are skilled to diagnose and treat mental disorders. These professionals are experienced in addressing some of the mental disorders, which makes them the best and most effective professionals for referrals (Runyan ; Khatri, 2014). Psychiatrists can provide medications as well as psychotherapy services. Psychologists are also non-medical practitioners who assist individuals with mental health problems to improve their overall functioning. These professionals have specialized in psychological disorders, which make them able to provide counseling services to clients with certain mental health conditions (Runyan ; Khatri, 2014). Clinicians might address the referrals through a collaborative approach where they involve the clients in the decision-making process as they make the referrals. Clinicians may know who to make referrals to through research and recommendations from other professionals in the organization (Runyan ; Khatri, 2014).
Since patients cannot refer themselves to healthcare providers, clinicians play an important role in helping clients in the referral process. There are employee assistance programs as well as local health departments, which are meant to help healthcare providers in obtaining referral information (Runyan ; Khatri, 2014). This provides a clear and a standard protocol for referral services, which help clinicians and other healthcare providers in making effective referrals. Clinicians can follow up with the referrals by scheduling appointments, which will help the clients in providing information on the effect of the referral in achieving the treatment goals (Runyan ; Khatri, 2014). Clients are also able to share some of the concerns, which might be bothering them related to the referrals. This also provides an opportunity for the clinician to support the client in different ways.
An initial treatment plan is important since this guides all other process, which follows the treatment process (Schwitzer ; Rubin, 2015). It is important for healthcare practitioners to be well prepared in addressing some of the mental health issues and be aware of the processes, which are involved in the treatment process starting from the assessment stage to the referral stage (Schwitzer ; Rubin, 2015). Assessment skills are important in conducting an effective diagnosis as a failure in this process may lead to misdiagnosis, which may affect other treatment processes and treatment goals. It is also important for clinicians to involve the family members in this process as they provide important information, which may not be provided by the client as sometimes the clients may be in denial or hesitant to provide this information (Schwitzer ; Rubin, 2015). A collaborative approach is also the best approach to address mental disorders, as voluntary involvement in the treatment process will enable the healthcare provider as well as the client to achieve the treatment goals (Schwitzer ; Rubin, 2015).
American Psychiatric Association. (2017). Anxiety disorders: DSM-5® selections. Arlington, Virginia: American Psychiatric Association Publishing.
Brown, T., ; Barlow, D. (2014). Anxiety and related disorders interview schedule for DSM-5 (ADIS-5). Oxford: Oxford University Press.
Okazaki, S., Kassem, A. M., ; Tu, M.-C. (2014). Addressing Asian American mental health disparities: Putting community-based research principles to work. Asian American Journal of Psychology, 5(1), 4-12.
Runyan, C. ; Khatri, P. (2014). Collaborative Family Healthcare Association Commentary on the ”Joint Principles: Integrating Behavioral Health Care into the Patient-Centered Medical Home”. Families, Systems, ; Health, 32(2), 146-146.
Schwitzer, A. M., ; Rubin, L. C. (2015). Diagnosis ; treatment planning skills: A popular culture casebook approach. Los Angeles: SAGE.