Reference no: EM133211745 , Length: Word Count: 4 Pages

Assignment - Treatment Plan Paper

Objective - Create a treatment plan.

A clinician takes many steps to determine what is best for a client who comes to him or her for help. Clinicians must interview, assess and refer, diagnose, and then create a treatment plan for clients. The treatment plan becomes the road map for the client and clinician to follow to reach the agreed upon goals. Having the data gathered helps show the rationale behind the developed plan, and the plan itself will then be used throughout treatment, amended throughout the process as needed.

Refer back to the case study: Read the scenario provided below:

Janet has come for free counseling at the clinic where you work. She wants to get some information and advice. Janet is a 21-year-old single female who lives with her boyfriend and his sister in New York City. She and her boyfriend have lived together since she was 18. Janet's parents were divorced when she was eight and her mother gained full custody of Janet and her siblings. Since Janet's father used marijuana, visitations were limited and stopped when Janet was 10. Janet began drinking at age 15 and smoking marijuana at age 17. She dropped out of high school with one semester left before graduation. Janet's boyfriend introduced her to cocaine and has kept her supplied since she moved in with him. When they can't afford cocaine they both combine a minimum of five beers with Valium to relax. Janet has noticed lately that her breasts are swollen and tender and she hasn't had a period in 12 weeks. She is pretty sure she is pregnant but doesn't want to stop cocaine, Valium, and alcohol use. She is seeking advice from you as to what to do in regard to having the baby because she isn't prepared to give up drugs.

Based on the assessment report: Client Assessment Report

The assessment process includes an evaluation of pertinent issues in the client and the need for a treatment plan. Previously, the client was interviewed to determine the presenting problem and recommend further assessment and treatment. Assessment procedures global criteria 12-16 include history assessment, finding corroborative information, assessment using evidence-based tools, and diagnostic evaluation of the client. This step is necessary in the lead up to planning the appropriate treatment plan in line with the diagnosis and strengths and weaknesses of the client. This paper presents a case summary of the patient, DSM-5 diagnosis criteria, tools used to assess the client with rationale, and a summary of the client's strengths and weaknesses.

Case Summary - The client is a middle-aged male with an alcohol use disorder (AUD). The client has experienced depressive episodes within the last year and reports increased uptake of alcohol. He reports having alcohol close by all the time while at work and at home. He has also recently experienced legal challenges due to drunk driving and reports that this is the first time he has had a challenge with controlling his drinking. He reports being irritable and moody when drunk and this has caused a challenge with relationships. The patient was recently fired from his job for coming in late and showing up intoxicated. The patient has also uncharacteristically taken loans, depleted his cash, and liquidated some of his assets.

Additional information about the client can be obtained from family members and partners of the client. Psychosocial history on how alcoholism has affected the client's relationships can be obtained. From the interview, alcohol use has affected the client's ability to perform effectively at work. It has also affected his relationships with family and friends. The client also experiences physiological challenges including irritability when drunk. Drunk driving is a risky behavior associated with alcohol consumption as well.

DSM-5 Diagnosis - Based on the diagnosis criteria for Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the client has AUD. A person with AUD has a strong craving for alcohol, finds it challenging to control its use, and continues to use in excess. According to DSM 5, a person has AUD if they have two or more of the 11 symptoms listed. The symptoms include consuming more alcohol than intended, has not succeeded in limiting alcohol intake, strong cravings for alcohol, continues drinking despite having consistent problems due to alcohol, and others (American Psychiatric Association [APA], 2013). In the current client, he has explained that he has cravings for alcohol and often drinks more than intended. He has also experienced relationship problems and financial problems associated with alcohol consumption. The client meets five of the criteria listed under DSM 5 and hence has moderate AUD (303.90 F10.20) (APA, 2013). This diagnosis determines the appropriate recommended action to promote recovery from alcohol use disorder.

Assessment Tools - Alcohol use screening tests can be used with the client to determine the major issues to be attended in treatment. Other than assessment using the DSM-5 criteria, the following two tools can be used for further client assessment to inform appropriate treatment plan and placement:

-Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS)

 -Helping Patients Who Drink Too Much: A Clinician's Guide (NIAAA)

This tool combines screening for drug use and assessment. Items on the tool can identify the frequency of alcohol and drug use as well as whether certain markers such as relationship problems have been present in the past. The tool can be administered by the clinician or the client. After answering all questions, the tool generates a risk level for the client and recommends action to be taken based on that risk level (McNeely et al., 2016). The rationale for using this tool is to identify any other drug use disorder that may be comorbid with the identified AUD. The tool is also useful for the current client to determine the severity of the use disorder and recommend the appropriate action to be taken including appropriate treatment and referral plans for this client.

This tool has been developed and endorsed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The guide defines the measure for 'drinking too much' as having 5 or more standard alcohol drinks per sitting or more than 14 drinks per week for men. For women, having 4 or more drinks per sitting or more than 7 per week are identified as drinking too much (NIAAA, 2017). The tool guides the clinician through the screening and assessment process. The first step of the guide is to ask about alcohol use, amount, and frequency. The second step involves assessing for AUD using criteria that have also been captured in DSM 5 diagnosis. The third step is brief intervention for people with at-risk drinking and those with dependence or abuse. Follow-up is the fourth step. Using this tool is appropriate for the current client as it guides the systematic steps to use for the clinician to support the client with brief intervention and appropriate follow-up. Therefore, combining this tool with the TAP tool can help create a more detailed case summary and recommendations for treatment.

Client Strengths and Weaknesses - The patient presents several strengths that may help in treatment planning. First, the client has accepted that he has a drinking problem and hence is ready for treatment. Acceptance is the first step in rehabilitation since the client can effectively surrender to treatment (Pagano et al., 2019). Secondly, the client has a high health literacy level. His ability to self-diagnose and understand the need for treatment is a strength as it assists in promoting change and recovery. Therefore, readiness for treatment and acceptance of the existence of a problem are major strengths for this client.

Elsewhere, the client has several weaknesses which should be considered. The client lost his job and hence may have trouble financing his treatment plan. Additionally, the client has ruined most of his relationships and consequently lacks a support system. A support system is important in encouraging behavior change and maintenance of sobriety (Pagano et al., 2019). The lack of one thereof increases the risk of relapse. Despite the weaknesses of this client, the assessment tools and client's willingness to implement the treatment plan can support his therapy and address the problems associated with AUD.