Week 7 and Week 9

COUN_6202_Wk07_CaseStudyMargeTreatmentPlanTemplate.docx

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Case Study: Marge Treatment Plan Template

INSTRUCTIONS and TEMPLATE for Marge’s Treatment Plan

1. Develop a hypothetical treatment plan for Marge based on The Case Study of Marge: Sessions 1–3). Begin with Marge’s admission into residential treatment (Sessions 1 and 2).

2. The plan should include Marge’s course of residential treatment and include:

a. Identification of the problem, goals to address the problem, and action steps.

i. Include 3 goals and 1 goal for discharge

b. Identify which ASAM dimension you are addressing.

c. The 12-month treatment plan should address the following:

i. Residential treatment

ii. Plans for discharge from residential treatment

iii. After care plans for the next 12 months

iv. All aspects of the case management of Marge’s treatment including

v. Counseling/treatment

vi. Family

vii. Social

viii. Vocational

ix. Legal

x. Mental Health

xi. Medical

d. Other areas that might be important to continued recovery

3. The overall plan should address problems/goals related to all aspects of Marge’s life that are related to her recovery and reflect the case management role of the counselor (e.g., counseling/treatment, family, social, vocational, legal, mental health, medical).

Plan adapted from:

County of Los Angeles Public Health. (2017). Specialty substance use disorder (SUD) system documentation examples. http://publichealth.lacounty.gov/sapc/NetworkProviders/ClinicalForms/TS/DocumentationExamplesSUD.pdf

Sample Treatment Plan

See next page for template.

Identified strengths : Strengths that will help client achieve long-term goal(s) (e.g., supportive family). Client should help identify. Initially it may be difficult to help client identify more than one or two strengths but as the course of treatment continues, more should become evident.

Identified problems/deficits : Factors in client’s life that may impede successful recovery

ASAM Dimensions: 1. Acute intoxication and/or Withdrawal Potential; 2. Biomedical Conditions and Complications; 3. Emotional, Behavioral, or Cognitive Conditions/Complications; 4. Readiness to change; 5. Relapse Continued Use or Continued Problem Potential; 6. Recovery Environment

Problem #1

Problem Statement:

Long-Term Goal:

Stated as broad desirable outcome that will be broken down into short-term goals and objectives. Usually, one long-term goal will be adequate for first year.

Example:

1. John will remain abstinent from use of heroin and all other mood-altering substances and behaviors for one year as demonstrated by negative random drug screens and self-report)

Treatment Start Date:

ASAM Dimension:

Short-Term Goals: Series of time-limited goals that will lead to achievement of long-term goal.

Example:

John will successfully complete residential treatment.

1. Short-Term Goal 1

Statements of what client will do to achieve short-term goal. Stated in measurable, behavioral terms

Example:

1. John will attend and actively participate in all individual and group counseling sessions.

John will admit he has an addiction problem.

Action Steps:

1. Short-Term Goal 1: Action Step: How objective will be carried out or accomplished

Example: Schedule one individual counseling session and five group counseling sessions weekly. John will complete Step One of the Twelve Steps

2. Short-Term Goal 2: Action Step:

Target Date:

Objective, measurable desirable outcome with timeframe

Example:

1. Staff and self-report of regular attendance and active participation in individual and group counseling sessions (30 days).

2. Self-report to counselor and members of group sessions (30 days).

Completion Date

Treatment Plan: Marge

Identified problems/deficits : Factors in client’s life that may impede successful recovery

ASAM Dimensions: 1. Acute intoxication and/or Withdrawal Potential; 2. Biomedical Conditions and Complications; 3. Emotional, Behavioral, or Cognitive Conditions/Complications; 4. Readiness to change; 5. Relapse Continued Use or Continued Problem Potential; 6. Recovery Environment

Problem #1

Problem Statement:

Long-Term Goal:

Treatment Start Date:

ASAM Dimension:

Short-Term Goals:

2. Short-Term Goal 1

3. Short-Term Goal 2

Action Steps:

3. Short-Term Goal 1: Action Step:

4. Short-Term Goal 2: Action Step:

Target Date:

Completion Date:

Identified problems/deficits : Factors in client’s life that may impede successful recovery

Problem #2

Problem Statement:

Long-Term Goal:

Treatment Start Date:

ASAM Dimension:

Short-Term Goals:

4. Short-Term Goal 1

5. Short-Term Goal 2

Action Steps:

5. Short-Term Goal 1: Action Step:

6. Short-Term Goal 2: Action Step:

Target Date:

Completion Date:

Identified problems/deficits : Factors in client’s life that may impede successful recovery

Problem #3

Problem Statement:

Long-Term Goal:

Treatment Start Date:

ASAM Dimension:

Short-Term Goals:

6. Short-Term Goal 1

7. Short-Term Goal 2

Action Steps:

7. Short-Term Goal 1: Action Step:

8. Short-Term Goal 2: Action Step:

Target Date:

Completion Date:

Discharge Plan

Identified problems/deficits : Factors in client’s life that may impede successful recovery

Discharge Plan

Problem Statement:

Long-Term Goal:

Treatment Start Date:

ASAM Dimension:

Short-Term Goals:

8. Short-Term Goal 1

9. Short-Term Goal 2

Action Steps:

9. Short-Term Goal 1: Action Step:

10. Short-Term Goal 2: Action Step:

Target Date:

Completion Date

Plan adapted from: