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Clinical Psychology and Counselling

Van

Van is a 43-year old Asian American male who is married with two young sons. He lives with his spouse and sons in the San Francisco area. He and his wife left Vietnam for the United States 7 years ago, and they own and operate a small nail salon and spa. Van was raised in a poor family and has little formal education. Aside from routine business conflicts, Van and his wife have gotten along quite well in their marriage and have always been supportive of each other. This changed abruptly last year when his oldest son, age 9, accused him of physical and sexual abuse. Because he described ongoing abuse while at school, Van’s son’s claim was reported to the state by one of his teachers. Since then, Van has had to make several court appearances, and this matter has put tremendous strain on the entire family. Although he denies the claims, Van has started to abuse alcohol since the accusation was made, and he will not talk to his oldest son or his wife. He does not use alcohol daily but is a binge drinker, consuming a large amount of whiskey two to three times per week and becoming very intoxicated. Van has never seen a therapist but is now court-ordered to seek psychological evaluation and treatment. He feels wrongly accused of these acts, although he admits that he has used physical punishment on both boys in the past. He believes that physical punishment is accepted in his native culture but is not understood in the United States. At this point, his marriage has suffered, as has his relationship with both sons. He has been unable to function at work since being accused of sexual abuse. While both of Van’s sons used to be excellent students, their grades have fallen, and the oldest son has behavior problems.

Roy

 

Roy is a single 37-year old African American male who is a part-time factory worker and lives with a roommate in an urban apartment in California. He has never been married, but he currently has a girlfriend. He has a high school education. He has chronic low back pain, blaming this on his job duties, which require some heavy lifting. He is involved in physical therapy and medical management for his condition. At work, Roy has had several incidents in which he became extremely angry with a coworker. In one incident, his supervisor observed his behavior, which he noted was physically threatening to the coworker. His behavior has been documented by his supervisor twice already, which has led to some job insecurity for Roy. Roy has been using high doses of Vicodin prescribed by his doctor for chronic pain. He is a smoker and uses alcohol daily. His estimate use is four beers a day, in the evening. He also uses prescribed medical marijuana on a daily basis. Aside from seeing a psychologist on the pain management team for six visits, he has not consulted with any mental health professional. The psychologist has taught him pain management strategies such as muscle relaxation, cognitive behavior therapy, and biofeedback, which Roy says have not helped much. In addition to the conflicts at work, Roy has had conflicts with his roommate, and most of these concern finances and housekeeping. His girlfriend of 4 years has started to wonder if her relationship with Roy is worth the effort. She says she ends up cleaning and helping Roy out financially, and she questions if this is what she wants in life.

 

Selena

 

Selena is a 31-year old Hispanic female who has divorced twice and lives alone in New York City. She has no children and is not currently in a relationship. She was a member of the Catholic Church, but stopped attending at age 24 because she stopped believing. She has completed 14 years of education, including 2 years of junior college. Her parents are divorced, and she has no contact with either of them. Selena has been working at a deli as a server for 4 years and has a good record. Prior to that, she worked as a stripper, as well as for an escort service on the side. While at these previous jobs and making a great deal of money, exceeding $8,000 per month, Selena was introduced to cocaine at age 23. She started snorting the drug occasionally then, but soon she began smoking crack and even injecting the drug. Despite her significant income, she would spend more than half of her money to support her habit. She has been self-admitted to both inpatient and outpatient treatment on three occasions and was introduced to Alcoholics Anonymous and Narcotics Anonymous as an aftercare plan. Although she went to these meetings for a while after each treatment, she eventually stopped attending and subsequently relapsed. When asked why she stopped, she stated that discussing alcohol and drugs in the 12-step meetings just made her crave them even more. Although no longer employed in the escort industry, Selena still uses cocaine on weekends. She smokes about a pack of cigarettes per day and drinks wine occasionally when using cocaine. Socially, Selena is somewhat isolated, but she does get together with a few friends, all of whom use drugs. Selena minimizes her current use of cocaine, claiming she only uses it for partying.

 

Frank

 

Frank is a 63-year old Caucasian male who is married with four adult children who have left home. He lives with his spouse in the suburbs of Kansas City. He is a business executive, working at a large healthcare corporation. He has a master’s degree in business management. He is 6 feet tall and weighs 275 pounds. He and his wife are very devout Christians. Frank’s demeanor is generally stoic, but he has secretly had a great fear of losing his job because of his advancing age, and he sees young employees every day at work who challenge him and who he believes want his job. Although they are financially stable, Frank has suffered some significant losses in his investments over the past 6 years. Frank believes that he cannot fail on any level at work, at least for the next 3 to 4 years. While employed at his job for over 15 years, Frank has been in many situations where he drinks socially and has been successful in using moderation and control, especially when around work associates. Within the last 4 years, however, he has started daily drinking at home after work, to the extent that his wife has noticed that he sometimes slurs his words and seems unsteady on his feet after dinner. He often falls asleep by 8:00 pm while watching TV. He drinks vodka martinis, and his wife estimates that he consumes almost a fifth of a gallon every day. Frank is a private man and has never expressed concern about his drinking. He does have annual physical exams through his company, and this year his doctor discovered that his liver tests were borderline abnormal, stating that it was probably due to alcohol use. He has not mentioned this finding to his wife, who he believes is too suspicious of his drinking, anyway. He is otherwise in good health, and he exercises regularly by running 5 days a week. He smokes an occasional cigar and uses no other drugs. When his wife repeatedly suggested that he go to counseling, he expressed that he did not believe it would be helpful, adding that he believed counselors are crazier than he is.

 

Guidelines for Writing a Treatment Plan

 

The process of developing a treatment plan involves a series of steps guided by the assessment and diagnosis. Assessment data may be gathered from a social history, physical exam,clinical interview, psychological testing, metrics, and or communication with significant others, which leads to the formulation of a diagnosis.

 

Goals and interventions must be attainable by the client, with an understanding of the client’s strengths and vulnerabilities. The treatment modality must also reflect the best possible approaches suited for the client’s personality, strengths, and limitations.

 

The following is one format for writing a treatment plan. Your treatment plan must be combined with the assessment and diagnosis for a comprehensive treatment plan.

 

Problem Selection and Assessment

 

  • Using a provided or contrived scenario, or an imaginary client, describe the assessment data and information determined about the client’s situation.
  • Identify the primary and secondary problems. Some other problems may need to be set aside if they are not urgent enough to require treatment at this time. An effective treatment plan can only deal with a few selected problems, or treatment is likely to lose its focus. As problems are revealed to the counselor, it is important to include the client’s prioritization of issues for which help is being sought.

 

Problem Definition and Diagnosis

 

Using the DSM (Diagnostic and Statistical Manual),identify the diagnostic criteria and codes associated with the previously described assessment information and problem selection.

 

Goals of Treatment

 

The best way to establish goals is to ask the client what he or she would like to change,as well aswhat the change would involve. Together, the counselorand client can formulate attainable goals.

 

Remember that goals are outcomes for the client and should be worded accordingly. For example, you would not classifylearn progressive relaxation skillsas a goal, as this is an intervention for the purpose of relief of anxiety symptoms.

 

You may also set short-term and long-term goals. A short-term goal might be to decrease anxiety symptoms. A long-term goal might be to resolve the cause of the anxiety, such as the employment issues. The following are examples:

 

  • Short-term goal
    • Relieve symptoms of anxiety.
    • Restore activities and social contacts to previous level.
  • Long-term goal
    • Resolve employment issues.
    • Improve sense of financial security.

 

Objectives and Interventions Identification

 

Objectives and interventions are used to meet the client’s treatment goals. Each objective should be developed as a step toward attaining the goals of the treatment plan. Interventions are the counselor’s actions designed to help the client complete the objectives.

 

This section of the treatment plan should identify at least three objectives and supporting interventions appropriate to the assessment and identified goals. The following is an example:

 

  • Objective: Identify the symptoms of posttraumatic stress disorder (PSTD) that have caused distress and impaired functioning.
    • Interventions:
      • Ask the client to identify how the traumatic event has negatively affected his or her personal relationship, functioning at work or school, and social and recreational life.
      • Ask the client to list and then rank the strength of his or her symptoms of PTSD.

Mode, Frequency, and Duration

 

Identify which theoretical modality or approach you would use to treat this client, including the number, frequency, and duration of treatment sessions.

 

Referral Resources

 

Include any possible outside referrals that might support or expand the client’s progress toward attaining his or her goals. The following are examples of referrals:

 

  • Career exploration class at a community college
  • Medical examination to rule out physical causes for symptoms
  • Anxietysupport group

Justification

 

Write a concluding justification for the determination of your diagnosis, goals, objectives, and overall treatment plan based on the information described in the scenario and assessment. Important questions to address include the following:

  • Is the approach appropriate when considering the presented problem and the client’s personality and motivation?
  • Does the plan reflect what the client wants to achieve?
  • What is your justification of selection of goals, objectives, and interventions?
  • Identify the progression of the counseling relationship through intervention and termination.
  • Identify strategies to address client resistance at various points in the therapeutic relationship.
  • Define the role of termination and referral in the counseling relationship as it applies to this client’s treatment plan.

 

 

 

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