Assignment 1: LASA 2: Assessment and Treatment Plan

As the intake worker at a local community mental health access center, a thorough assessment needs to be completed for every person that comes in looking for support and services. Because of the variety of illnesses and treatment options, the more accurate your assessment and treatment plan the more help you will provide for the client.

 

Choose from one of the provided case studies  to complete the assessment and treatment plan  using the template provided.

 

Directions:

 Choose a case study.Fill out the assessment and treatment form.

 

Write a separate summary at the end of the form explaining the best psychological theory that would best fit understanding this case study. Be sure to include ethical and cultural considerations.

 Assignment 1 Grading Criteria Maximum Points Assessment form.20Description of the disorder and explanation of the symptoms best explain the behavior of the case study.32Apply assessment information to treatment planning stage.36Choice and justification of a theory that fits best with this particular case.32Complete treatment plan form.20Summary of case study.28Analysis of the most appropriate treatment theory.36Explanation of where ethical and cultural considerations may arise and what could be done to provide ethical and culturally sensitive treatment.32Organization: Writing, Ideas, Transitions, and Conclusion16Usage and Mechanics: Grammar, Spelling, and Sentence structure16APA Elements: Attribution, Paraphrasing, and Quotations24Style: Audience, and Word Choice8Total: 300 

 

    *   Case Studies to choose from  Just choose  The easiest one an there is a Acessment form that needs to be completed all are attached.

 Case Study #1

 

Young-Hwa, a 40-year-old Korean male, had immigrated to the United States 15 years ago without proper documentation. He had a hard life because, despite his training as a chef in Korea, he had difficulty finding a well-paying job without proper documentation. He also had a hard time getting along with others for long periods of time in some of the kitchens that he worked for.  He would do really well for a while talking about how much he enjoyed the job thinking that this was going to be his lucky break, but after several months he would either quit or get fired.  During these times of being out of work he is very depressed and irritable and will sleep for days without coming out of his bedroom.  After many years of various positions including kitchen assistant and assistant cook, he finally landed his dream job of a top chef in a Korean restaurant.

 

He recently was married to a Caucasian woman who had a daughter from a prior relationship and now they have twin sons.  Their marriage would be described as fairly good with some hard times.  His wife knows his work history and occasionally will threatened that if he messes this one up, she and the children will be leaving him.  However, most of the time she only threatens this when she is angry about not being able to pay a bill, which causes them to fight.  The other main topic of conflict is how he never had time for her and her daughter, but now spends more time with them with the birth of his sons.  He claims he just has more time and energy now.  He also is so excited about the new position, reassures her that it will not happen this time, and begins to stay up late into the evenings excitedly planning new menus. Even when he is home, he is busily making new dishes for her and their neighbors to try.

 

They live in a predominant Koran neighborhood and most of the couples are kind to his wife and step-daughter, but occasionally question her about Young-Hwa’s behavior.  They mention to her that it is hard to know what you are going to get when you see him.  She dismisses their concerns and explain it away with his stress of jobs and not having his proper documentation of his training in Korea and hope that his paperwork that was submitted after their marriage for citizenship will get approved and that will help his mood.

 

Young-Hwa is the oldest child with having three younger sisters that still live in Korea near where his elderly parents live.  The oldest of the sisters actually lives with and takes care of his parents.  He secretly sends his sister money to help with taking care of his parents but feels he cannot tell his wife because of her complaints about money and that she would just not understand.

 

(Source:   http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A68623#A68762

 

Chapter 3 – Clinical Issues Related to Integrating Vocational Services

 

 

 Case Study #2

 

Julia is a 27-year-old Italian American female. She was referred to a specialty residential program by the child protective services agency because her daughter was born with a toxicology screen that tested positive for heroin, cocaine, and marijuana. In order to keep her baby, she was required to participate in this program with her infant daughter. Julia was administered a battery of assessment measures during her intake interview for residential treatment. These measures included the ASI (which measured her functional status in seven domains) and the Self-Directed Search (which determined her vocational interests and skills).

 

Julia is an only child. She lives with her mother, a nurse, and her father, an electrician. Her parents were given temporary custody of her daughter while she was waiting for placement at the residential program. The clinician learned, however, that she and her parents have had several physical fights recently, of which the child protective services agency was not aware.

 

Julia has had 13 years of education. She had been a nursing major at the local community college 5 years ago but dropped out when she could no longer manage school due to her polysubstance use. Julia has been drinking to intoxication on Friday, Saturday, and Sunday since the age of 15. She has also injected heroin regularly (about three times per week over the last 5 years) and has been smoking or snorting cocaine on weekends. She often used more than one substance per day–usually cocaine and alcohol–when she could not get heroin.

 

Julia has been arrested for assault, breaking and entering, and robbery. However, she was not convicted and has never been incarcerated. Julia usually got her money for drugs by stealing or by giving sexual favors. Julia has several close male and female friends who are also using drugs. She has had serious conflicts over the last 30 days with her parents, sexual partners, and friends. She reports that her current sexual partner, who sells drugs and is the father of her child, has physically and emotionally abused her.

 

Julia has been hospitalized twice for suicide attempts. She says that periodically she becomes severely depressed, can’t eat or sleep, cries a lot, can’t sit still, and has trouble getting out of bed. She is easily irritated when she is depressed and sometimes has difficulty controlling her anger. Julia also has panic attacks and is, at times, fearful of crowds, stores, classrooms, and restaurants where she does not know people. She is also afraid they will see her having a panic attack and think that she is crazy. Julia has been prescribed imipramine (Tofranil), lithium (Lithonate), and diazepam (Valium), but none of these medications seem to help. She finds it easier to get herself out of bed after she has used heroin or cocaine. Julia admits that her drug use may be a form of self-medication because she “feels better” after she uses.

 

Julia’s ASI composite scores reveal that she is most in need of treatment in the areas of alcohol and drug use, employment, social relations, and psychiatric problems. Julia herself rates her need for treatment in the areas of alcohol and drugs and in psychological functioning as extreme, but she views her need for employment and social counseling as slight.

 

Julia’s result from the Self-Directed Search matches her vocational dream of becoming a nurse (like her mother). Julia was surprised to learn that her summary code was also consistent with dietician, physical/occupational therapist, and psychiatric technician. She was particularly interested in the physical and occupational therapy fields because she thought these occupations would limit her access to drugs and thus eliminate the temptation to steal them, while still allowing her to work with people in a medical setting.

 

When Julia was approached about further vocational exploration, she said that the thought of going back to school made her highly anxious and that she did not think she could ever see herself getting up to go to work or performing adequately on the job. She felt that she had been using drugs too long and “hanging out” so long with other users that she did not even know how to talk to “straight people.” She also felt humiliated about all her arrests and about “doing nothing with her life” all these years, so she couldn’t imagine filling out an application to go back to school or interviewing for a job.

 

 

 

(Source:  http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A68623#A68762

 

Chapter 3 – Clinical Issues Related to Integrating Vocational Services)

 

 

 Case Study #3

 

Joe is a 34-year-old, unmarried, African-American man who lives in a poor neighborhood of a large city and works as a dock loader for a large trucking company. He returned from war nine months ago after serving in an 18 month deployment. Joe lives with an aunt and uncle, paying a small monthly rent for a basement room, after losing his own apartment a couple months ago.  He generally keeps to himself, although he has a few war buddies that he occasionally hangs out with.

 

Joe never knew his father and was raised by his grandparents. His alcoholic mother left Joe and two younger brothers in his grandparents’ care when she ran off with a man—only to die in an accident about a year later when Joe was 8 years old. His beloved, very religious grandfather died of complications from diabetes when Joe was in high school. Although his grandmother is alive still, Joe seldom sees her. None of the family members are close and he hardly know the aunt and uncle he is living with.

 

Now Joe is in serious trouble: a street brawl that he got into after returning from a bar with friends ended with the shooting death of one of his friends. Joe is one of those charged, though he swears he was not involved. He was, however, so drunk that he does not remember what happened. Because Joe has a history of fighting and a series of previous assault charges, the court has mandated treatment because of the alcohol found in Joe’s urine after his latest arrest.

 

Joe is overweight but otherwise reports no physical complaints or serious medical problems.

 

The one bright spot in Joe’s life is the 4-year-old son, Charles, he fathered with a “nice” girl (Brianna) he has known since high school. Brianna says that she loves Joe and would like them to be a family. However, she is very concerned about Joe’s erratic behavior and is thinking about ending the relationship. Although Brianna knows that Joe thinks Charles is special, she is reluctant to let the father and son go anywhere together—fearing that Joe might get triggered and go into “anger mode” as she calls it. Brianna is a stabilizing influence on Joe, with a strong spiritual side that reminds Joe of his grandfather. However, says he is not the same guy that he was before the war and is sometimes afraid of him when he “zones out”. Also, Joe knows that his job is in jeopardy if he does not show up for work more regularly. He has been skipping work after times of being blacked out and not remembering his actions.  Joe does not have many opportunities to increase his income and has no aspirations for a better job fearing doing something different. Also, it seems as though the more worried he is, the more he gets upset by things that happen around him.

 

When asked, Joe says he wants change and become a man like his grandfather. However, he does not see a way out, especially if he is convicted of manslaughter. The thought of spending time in prison terrifies him.

 

(Source:  http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hssamhsatip&part=A88941#A89068

 

 Initial Assessment / Mental Status Check

 

 Name of Client ________________________________________________              Date_____________________

Appearance:

__Well groomed    __Neat   __Casual    __Unkempt   __Unclean    __Inappropriate   __Bizarre   __Unusual

General Presentation:

__Cooperative   __Guarded    __Distractible    __Agitated

Speech:

__Clear   __Tone (loud/soft)  __Rhythmic   __Poverty of Speech   __Rapid   __Slow  __Stutter __Pressured  __Slurred

Affect:

__Appropriate   __Blunted     __Melancholy   __Restricted     __Labile    __Inappropriate    __Flat

Mood:

__Even   __Depressed/sad    __Anxious      __Irritable   __Angry    __Elevated  __Euphoric/elated __Expansive    __Passive   __Pessimistic   __Blunted

Orientation:

__Time    __Place    __Person

Intelligence Level:

__High    __Average    __Low    __Retarded

Judgement:

__Rational    __Impaired    __Immature    __Impulsive

Insight:

__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 __Abstract

Comments:  __________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________

 

 RISK STATUS CHECK

 

 Violence/Abuse: (Domestic and Workplace, Child and Sexual)

Present Risk:      ____None            ____Low             ____Moderate    ____High

Current:  ___________________________________________________________________________________________________

____________________________________________________________________________________________________________

Past: _______________________________________________________________________________________________________

____________________________________________________________________________________________________________

Suicide/Homicide: (Past attempts, Prior inpatient admissions, Ideation, Intent, Attempt, Plan, Compromised ADL’s)

Present Risk:      ____None            ____Low             ____Moderate    ____High

Current: ___________________________________________________________________________________________________

__________________________________________________________________________________________

Past:  ______________________________________________________________________________________________________

____________________________________________________________________________________________________________

Other risks:  (eating disorder, history of multiple diagnoses, non-compliance with earlier treatment, runaway): ____________

____________________________________________________________________________________________________________

Symptoms:  Weight gain/loss     Sleep decreased/increased    Concentration increased/diminished    Interest level decreased    Fear

Restlessness     Increased arousal     Racing thoughts    Irritability     Avoidance    Hopelessness  

 

 CLIENT RESOURCES

 

 Strengths identified by client ____________________________________________________________________________________

____________________________________________________________________________________________________________

Additional client strengths seen by clinician ________________________________________________________________________

____________________________________________________________________________________________________________

Family members/others who will be supportive of client in treatment ____________________________________________________

____________________________________________________________________________________________________________Family member/support people to have involved in treatment __________________________________________________________

____________________________________________________________________________________________________________

 

 

 CLINICAL 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.)

 

 ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

 

 

 

 

 

 

  

DIAGNOSIS

 

  

Axis I    ________________________________________________________        

               ________________________________________________________                       

 

Axis II  ________________________________________________________        

 

Axis III ________________________________________________________

               ________________________________________________________

 

Axis IV ________________________________________________________

               ________________________________________________________

 

Axis V   Current GAF:  __________         Highest past year _____________

 

 

 

 

 

 

  

PROGNOSIS

 

  

____Excellent                    ____Good                         ____Fair                     ____Guarded                    ____Poor

 

Comment: __________________________________________________________________________________________________

____________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Plan

 

 

 

 

 

                                                                                               

 

 

 

Psychological theory and explanation of fit  (humanistic, behavioral, psychodynamic, cognitive, social-learning, self theories):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Therapy Choice and Treatment Strategy:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                                                                   

 

Particular Goals and Objectives (interventions) for client:                                       1._________________________________________________________                 _________________________________________________________

 

   _________________________________________________________

 

   _________________________________________________________ 

 

a.___________________________________________________                            

 

b.___________________________________________________                                     

 

2._________________________________________________________                          

 

   _________________________________________________________

 

   _________________________________________________________

 

   _________________________________________________________

 

a.___________________________________________________                            

 

b.___________________________________________________                        

 

3._________________________________________________________                          

 

   _________________________________________________________

 

   _________________________________________________________

 

   _________________________________________________________

 

a.___________________________________________________                            

 

b.___________________________________________________                        

 

   

 

 

 

 

 

 

 

 

 

 

 

Summary:

 

 

 

Summarize the case study with the diagnosis and plan of action.

 

 

 

Explain why the treatment plan chosen is the best.

 

 

 

Critique the plan and explain where ethical and cultural considerations may arise and what could be done to provide ethical and culturally sensitive treatment.

 

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