Expert answer:discharge summary
Expert answer:Part 1: Using the revised treatment plan, complete a discharge summary for your client using the “Discharge Summary” template. This discharge summary should address the following: What behaviors would indicate that the client is sustaining at a healthy baseline?How would you determine if Eliza met her treatment goals?What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services? (Recommendations should be based on the information gathered for second mandatory evaluation).How would you encourage involvement in community-based resources? Part 2: Write a 700-1,050-word summary statement about your client, Eliza. Include or address the following in your summary statement: Demonstrate whether or not the client met the goals of the treatment plan.What specifically contributed to the success of the treatment plan or lack thereof?What language would you use to communicate the outcome to the client?How would you document the final session?Include at least three scholarly references in your paper. REF: Schwitzer, A., & Rubin, L. (2015). Diagnosis & Treatment Planning Skills. Thousand Oaks: Sage Publications Inc.
discharge_summary_template.docx
treatment_plan_revised.docx
eliza_treatment_plan_report_revised.docx
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Discharge Summary Template
Directions: Complete the Discharge Summary form by addressing the fields below.
Client Name: [Enter the client’s name here]
Date of Birth: [MM/DD/YYYY]
Date of Admission: [MM/DD/YYYY]
Date of Discharge: [MM/DD/YYYY]
Presenting Problem Upon Admission:
[State the client’s presenting problem upon admission here.]
Current Medication:
[List the client’s current medications here.]
Reason for Discharge:
Resources
and Referrals:
[State the client’s
reason for discharge here.]
[List the client’s resources and referrals here.]
Projected Prognosis:
[State the client’s projected prognosis here.]
Eliza D 00/00/00
Client Signature & Date
Case Manager Signature & Date
Revised
Treatment Plan
Based on the information collected complete the following treatment plan for your client Eliza. Be sure
to include a description of the problem, goals, objectives, and interventions. Remember to incorporate
the client’s strengths and support system in the treatment plan.
Client: Eliza D Date: 07/12/2017 Age: 18 DOB: 1999
DSM Diagnosis
ICD Diagnosis
Substance Abuse
Substance Abuse
Personality disorders
Anxiety
Anxiety
Goals / Objectives:
□ Mood Stabilization
□ Anxiety Reduction
Interventions:
Frequency:
□ Psychotropic Medication Referral &
Consultation □ Journaling
□ Weekly □ Bi Weekly □
Monthly
□ Cognitive Behavior Therapy
□ Skill Training
□ other:
____________________
□ Emotion Recognition – Regulation
Techniques
□ Group □ Individual □
Family
□ Psychotropic Medication Referral &
Consultation □ Journaling
□ Weekly □ Bi Weekly □
Monthly
□ Cognitive Behavior Therapy
□ Skill Training
□ other:
____________________
□ Relaxation Techniques
□ Group □ Individual □
Family
□ Reduce Obsessive Compulsive □ Psychotropic Medication Referral &
Behaviors
Consultation □ Journaling
□ Cognitive Behavior Therapy
□ Skill Training
□ Weekly □ Bi Weekly □
Monthly
□ other:
____________________
□ Group □ Individual □
Family
□ Decrease Sensitivity to
□ Verbalize Memories Triggers &
□ Weekly □ Bi Weekly □
Revised
Trauma Experiences
□ Establish and Maintain Eating
Disorder Recovery
□ Maintain Abstinence from
substances (Alcohol/Drugs)
Emotion
Monthly
□ Desensitize Trauma Triggers and
Memories
□ other:
____________________
□ Utilize Healing Model/Support
(Mending the Soul)
□ Group □ Individual □
Family
□ Overcome Denial □ Identify
Negative Consequences
□ Weekly □ Bi Weekly □
Monthly
□ Menu Planning □ Nutrition
Counseling □ Body Image Work
□ other:
____________________
□ Healthy Exercise □ Trigger Mngmt
Recovery Plan □ CBT
□ Group □ Individual □
Family
□ Substance Use Assessment □ Step
work □ Overcome Denial □ Identify
Negative Consequences □
Commitment to Recovery Program □
Attend Meetings □ Obtain Sponsor
□ Weekly □ Bi Weekly □
Monthly
□ other:
____________________
□ Group □ Individual □
Family
□ Increase Coping Skills
□ DBT Skills Training □ Problem
Solving Techniques
□ Weekly □ Bi Weekly □
Monthly
□ Emotion Recognition & Regulation
□ Communication Skills
□ other:
____________________
□ Group □ Individual □
Family
□ Stabilize, Adjustment to New
Life Circumstances
□ Decrease/Eliminate Self
Harmful Behaviors
□ Alleviate Distress
Behavior Therapy
□ Cognitive
□ Weekly □ Bi Weekly □
Monthly
□ Stress Management □ Skills
Training
□ other:
____________________
□ Improve Daily Functioning □
Develop Healthy Support
□ Group □ Individual □
Family
□ Cognitive Behavior Therapy □
Skills Training
□ Weekly □ Bi Weekly □
Monthly
□ Develop and Utilize Support System □ other:
____________________
Revised
□ Group □ Individual □
Family
□ Improve Relationships
□ Communication Skills □ Active
Listening □ Family Therapy
□ Assertiveness □ Setting Healthy
Boundaries
□ Weekly □ Bi Weekly □
Monthly
□ other:
____________________
□ Group □ Individual □
Family
□ Improve Self Worth
□ Affirmation Work □ Positive Self
Talk □ Skills Training
□ Weekly □ Bi Weekly □
Monthly
□ Confidence Building Tasks
□ other:
____________________
□ Group □ Individual □
Family
□ Grief Reduction and Healing
from Loss
□ Develop Anger Management
Skills
□ Psychoeducation on Grief Process/
Stages
□ Weekly □ Bi Weekly □
Monthly
□ Process Feeling □ Emotion
Regulation Techniques
□ other:
____________________
□ Reading/Writing Assignments □
Develop/Utilize Support
□ Group □ Individual □
Family
□ Decrease Anger Outbursts □
Emotion Regulation Techniques □
Cognitive Behavior Therapy
□ Weekly □ Bi Weekly □
Monthly
□ Increase Awareness/Self Control
□ other:
____________________
□ Group □ Individual □
Family
Revised: Eliza Treatment Plan Report
Eliza Treatment Plan Report
1
E. Treatment Plan
2
Eliza Treatment Plan
From the documents presented after filling by Eliza, it is not immediately clear what
condition the client is undergoing. The document required a bit of exploration and examination
to help determine the diagnosis and the interventions appropriate for Eliza. Examination,
therefore, would include further questioning of whether she had experienced similar feelings
prior to joining college and if she can identify when she began feeling that way and being
stressed. Answers provided to these questions would not only help in proper diagnosis but would
also give insight on the best treatment plan. Eliza can also be engaged in a discussion that
explores some of the highlights she has experienced in the recent past and the moments when she
did not feel stressed or have an identity crisis and how long those moments lasted. The purpose
of having that discussion would be to indicate the triggers and the root of the problem.
Additionally, talking concerning her relationships such as parents, siblings, caregivers,
friends and the even classmates would help in showing the status of her relationships. For
instance, her frequency of seeing her family would also help in the process. As a therapist, the
health of her relationships would be a significant illustration of the role played by the people
close to Eliza and her diagnosis (PsychGuides, 2016). On the other hand, the interest she has in
being with other people such as the desire to join clubs, associations, and societies on campus is
helpful in the creation of an intervention plan. The choice of therapy relies heavily on the results
obtained from the engagement and exploration with the therapist and Eliza.
Eliza’s completed form on the Level 1 Cross-Cutting Measure contained crucial
information on several areas of her life. In one of the questions, she sighted that she had
decreased interest and loss of pleasure. Seeing that the feeling was previously absent, evaluating
the possible reasons behind her loss in interest is a step towards acquiring her help. Conversely,
E. Treatment Plan
3
Eliza suffers from anxiety, which leads her to avoid social situations. To combat her anxiety, she
has to identify the situations that make her anxious and some of the ways she has used in dealing
with her anxiety. These two objectives would help in replacing her intervention in reducing her
anxiety and implementing ways that help her recover. Further investigation on the low selfesteem and identity crisis illustrated by the results would also be good in showing the
relationship between her anxiety, self-esteem, and her relationships with her family and friends.
For instance, finding out if her high school friendships were characterized by the same traits she
is currently exhibiting would be vital for treatment planning.
Change in environment, college stress and problems adjusting to a different routine were
some of the challenges identified in Eliza’s completed form. Her burdens stem from the
assignments and her inability to know what she wants out of life. These two elements have
influenced her social life and her emotional wellbeing. On top of that, Eliza does not have a
support system, and this further complicates her situation. In fact, the alcohol and drug use is not
among her primary/fundamental problems. Eliza does not have a drug or alcohol dependency
problem and her using these substances was a coping mechanism. Moreover, she used them with
the aim of creating friendships in school and fit in the new life in college. Following all the
information provides, exploration and examination of Eliza’s case, the diagnosis I made was that
she has adjustment disorder and depressive disorder. The diagnosis was arrived at after careful
consideration of the symptoms exhibited by Eliza and the information provided.
Eliza would significantly benefit from the Cognitive Behavioral Therapy for both
diagnoses (Leichsenring et al., 2014). The fundamental purpose is to reduce her symptoms and to
help her shape a positive worldview. It will also help her in improving her relationships with
family and friends. One of the intervention methods will be journaling whereby Eliza will be
E. Treatment Plan
4
required to document how she feels throughout the week as a way of identifying the trigger and
the oscillation of emotions. It is during therapy sessions that the entries to her journal will be
evaluated and reviewed. Tips and techniques on how to handle the low points and other issues
identified to form the journal review will be given. Furthermore, encouraging Eliza to perform
outside of her comfort zones such as encouraging her to join clubs and associations in school will
be a great boost to her mood and ability to make friendships in college. The therapy will be
conducted for eight weeks and in each week, the period will be an hour. After completing the
timeline, she can access therapy at will, and at any moment, she desires to do so. Conversely, her
family and particularly her parents might require family counseling. The family counseling
sessions will be effective in providing a platform for openness. Eliza will have the opportunity to
tell her parents some of the challenges she is going through in college and this actions would
help their strained relationships.
Making use of the Level 2 Depression Cross-Cutting Measure would be critical in
determining and monitoring depression-related symptoms in Eliza (American Psychiatric
Association, 2013). Change of the method used will be shown by the results from the level two
measurement results. Monitoring of her progress will also be achieved through the Patient Health
Questionnaire. The assessment point is in line with the goal of treatment in reducing Eliza’s
symptoms of depression.
E. Treatment Plan
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Part 2
Eliza Treatment Plan Report
Eliza a college student aged 18 years old in her freshman year got into trouble with the
school authorities. She is of Caucasian descent with a lean body and of average height studying
engineering at the school. Her parent’s home is approximately two hours away from the college,
and thus Eliza can visit whenever she likes. Eliza went for counseling following an event that
took place in her dorm room a few days before. Eliza and friends in her dorm room were caught
with alcohol which is illegal since her school is an alcohol-free zone. She admitted to having
partaken in alcohol but because her friends were also taking alcohol. She also claimed having felt
tipsy or using her word buzzed while her friends were drunk.
The treatment plan is reliable since it focusses on the problem areas of the client. The
client has issues with her relationships and also suffers from social anxiety. Moreover, they have
stresses in school that has led them to withdraw from people thus unable to make friends.
Change in environment, college stress and problems adjusting to a different routine were some of
the challenges identified in Eliza’s completed form. Her burdens stem from the assignments and
her inability to know what she wants out of life. Eliza would significantly benefit from the
Cognitive Behavioral Therapy for both diagnoses.
The fundamental purpose is to reduce her symptoms and to help her shape a positive
worldview. It will also help her in improving her relationships with family and friends. One of
the intervention methods will be journaling whereby Eliza will be required to document how she
feels throughout the week as a way of identifying the trigger and the oscillation of emotions. It is
during therapy sessions that the entries to her journal will be evaluated and reviewed. Tips and
E. Treatment Plan
6
techniques on how to handle the low points and other issues identified to form the journal review
will be given. Furthermore, encouraging Eliza to perform outside of her comfort zones such as
encouraging her to join clubs and associations in school will be a great boost to her mood and
ability to make friendships in college. The therapy will be conducted for eight weeks and in each
week, the period will be an hour.
Eliza is experiencing several problems as mentioned but the treatment plan chosen is
appropriate to help her achieve the goals she has set. Her wellbeing is put at the forefront and is a
primary objective in the process. The cognitive behavior therapy is more hand on and a more
practical approach based on the findings. It is used to treat a series of issues in a client and thus
achieve more than if the treatment plan was subdivided treating each issue separately. The plan
adheres to the ethical policies and regulations and therefore does not affect the client negatively.
Some of the benefits associated with the use of cognitive behavior therapy include significant
reduction of depression symptoms, anxiety, and addictive behaviors. Additionally, it also
improves the client’s confidence and self-esteem.
The changes to the treatment plan mean that the treatment period will take longer than
expected. The number of the session will be increased, and there will also be an increase in
monitoring the client’s progress. For instance, requiring Eliza’s family to have a session with her
means that the treatment plan will be divided as such that Eliza has independent sessions and
later sessions with her family.
Evaluation of the resources available to make a referral would be conducted by assessing
my skills set and identifying areas that I am less competent and equipped for such that the
referral is competent in those areas. The discussion would also be done with the client to
E. Treatment Plan
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communicate the fact that referrals would help her recover and achieve her goals. Follow up of
the referrals made after the client has transitioned to the other treatment plan is also necessary.
Explanation to the client for the need to do referrals would be done by explaining the
importance of receiving help from a qualified professional. Therapists should seek supervision
when the cases they are working with fall outside of their scope, and they need the help of an
experienced therapist to solve the case. Another instance that may warrant the need for
supervision of therapists is when the client is dangerous or when the therapists are not able to
remain professional and become too invested in the case. Supervisions enable the therapists to
carry out their duties within the scope of professionalism and ensure the safety of both the
therapist and the client. Apart from having a supervisor in some cases, another important aspect I
want to develop as a therapist is to increase my awareness of diversity when working with
clients.
The referrals that I would suggest to the client are concerning their inability to form
relationships with family and friends. The referrals would be a therapist that is equipped in the
area of relationships.
Using case conceptualization techniques would be a critical way of assessing the client.
Collecting and analyzing this information is crucial to understanding the client and forming
collaborations that enable them to achieve set objectives and goals. Any patterns of the client’s
mental illness if present can be determined by use of different methods. For the counselor to be
able to identify the areas that will provide information concerning the patterns of mental illness
in a client, they first have to establish trust and clear communication. This confidence can be
built on the first interaction at this moment the client will have an exchange that takes the form
of an interview. For instance, the counselor can gather from the client’s presentation how the
E. Treatment Plan
8
client perceives their world. Comparison between healthy perception and any patterns of illness
can be recognized, but further information would be required (Fulkerson, 2015). Information not
provided by the client can be sourced from the forms filled such as demographic information,
social, historical, cultural contexts of the client (Schwitzer & Rubin, 2015).
E. Treatment Plan
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References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th Ed.). Washington, DC: Author.
Anxiety Disorder Treatment – Symptoms, Rehab & Recovery. (2018). Psychguides.com. Retrieved 3
January 2018, from https://www.psychguides.com/category/anxiety/
Leichsenring, F., Salzer, S., Beutel, M., Herpertz, S., Hiller, W., & Hoyer, J. et al. (2014). LongTerm Outcome of Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social
Anxiety Disorder. American Journal of Psychiatry, 171(10), 1074-1082.
http://dx.doi.org/10.1176/appi.ajp.2014.13111514
Schwitzer, A., & Rubin, L. (2015). Diagnosis & Treatment Planning Skills. Thousand Oaks: Sage
Publications Inc.
…
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