week 5

Psychosocial assessment is important in therapeutic settings, especially when treating a patient’s condition. This assessment helps in developing a plan and course of action for the patient so that the best treatment plan can be developed (Baldwin et al., 2018). This paper will develop a discussion regarding the intake process, biopsychosocial assessment, treatment planning, and referral process based on Eliza’s information.

Intake

The patient is an 18-year-old Caucasian female currently going to school at City University who went for counseling after being found taking alcohol in her dorm room at the university; an alcohol-free campus. She filled out an intake document indicating feelings of low self-esteem, anxiety, and stress. A Level 01 Cross-Cutting Measure (CCM-1) was also administered. The client had a mild rating on avoiding situations that make her anxious and a slight rate of little interest or pleasure in doing things. She also had a slight rating for problems with sleep that affected her sleep quality, not feeling close to other people, and not knowing what she really wanted out of her life.

The CCM 1 can be used in building a treatment plan based on how the patient answers the questions according to the ranks. The CCM-1 can be utilized by reviewing how each question was answered because this will provide insights on how to effectively evaluate the client’s mental health and come to a conclusion. (Kwan et al., 2019). According to the answers provided by the patient, CCM-1 can be utilized to identify whether there is a need for further investigation using the Level 2 Cross-Cutting Symptom Measure.

Several specific questions that would need to be answered at the end of the psychosocial assessment are described below: How many close friends do you have? Are you under pressure from your peers to drink? Are you still taking alcohol? Are most of your friends drinkers? Are you able to describe any specific situations that make you feel more anxious? How many hours do you sleep?

Biopsychosocial Assessment

To gain a better understanding of the client's biological, psychological, and social status, a biopsychosocial assessment in the context of a comprehensive evaluation would be required. By the end of the assessment, an improved understanding of the client’s problem will be obtained, and it will be easy to identify various resources that are available for the patient. This will then be followed by a translation of the findings, diagnosis, and development of an intervention plan.

According to her assessment, the patient has a small body and is of average height. The patient did not sit close to the examiner during the assessment and sat in the corner of the room. She explained that she did not attend the treatment voluntarily and did not maintain eye contact but looked at her fingers or the floor. She blames campus for contributing to her life stressors, explaining that she had hoped life would be as easy as it was in high school. She has a fair relationship with her parents, referring to her father as the good guy and her mother as the controlling type.

The initial treatment goals and plan for this patient would involve alleviating symptoms that make her anxious or give her stress with psychotherapy. This would involve understanding the cause of these stressors and teaching the patient how to better manage her time or seek the help of a tutor. It would be prudent to teach the patient three new coping skills, including better communication skills with her friends and family, meditation, and relaxation exercises. Also, the treatment goals and plan should involve focusing on improving her social skills as well as regulating her sleep patterns by getting her to sleep at least 8 hours each night.

Treatment Planning

Castillo et al. (2016) explain that CCM-2 is important in creating more in-depth evidence of the symptoms, thus justifying the diagnosis, the treatment plan, and the need for a follow up. Based on the information about the patient, level 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form) anxiety would be the most effective for future sessions. The CCM-2 seem to is appropriate since the patient scored mild in the anxiety domain (Castillo et al., 2016). DSM-5 explains this tool to be an effective follow up in future therapeutic sessions (Castillo et al., 2016). ADNIM-6 will also be used together with the Hamilton Anxiety Rating Scale (HAM-A).

The assessment findings need to be conveyed to the patient and her family. This will help to ensure the avoidance of harm. It can be achieved by communicating with the patient, ensuring that she is comfortable with her family being involved in the therapeutic progress. The assessment findings should then be conveyed to the patient in a simple language that can be easily understood. Once the client consents to her family involvement, her parents can be told about the assessment findings through one-on-one sit downs or via a confidential written letter.

Prioritizing the patient's needs should be based on issues that relate to the troubles she is having while adjusting to campus life and anxiety related to social situations. Focus should then be placed on her sleeping problems as well as assisting her to recognize her ambitions in life. Attending to the patient's needs can involve recommending that she gets help from a tutor, joins a school club, or recommending ways that she can use to reduce stress and anxiety as they relate to school. The patient can be required to start by joining a club or sorority, continuing to make friends, and then proceed to attend one social school setting that does not involve alcohol.

Referral

Addressing possible referrals can be done through effective communication of the counselor’s concerns about the patient. The counselor should inform the patient if the help she needs is beyond their qualifications, meaning that they lack competency for this matter (Baldwin et al., 2018). Other situations that may warrant referrals include acts of disrespect, the patient missing therapy sessions, and if the patient shows unwillingness to participate in the treatment sessions (Baldwin et al., 2018).

The counselor may consult with superiors and coworkers about possible referrals and may also assess a person who has the competency or qualifications that best suit the needs of this patient. The counselor should make sure to conduct a follow up after the referral to find out whether it is working for the patient. This will help to understand whether the referrals made were appropriate, how any adjustments can be done, and any role that the counselor can play in maximizing the progress of the patient (Baldwin et al., 2018).

Conclusion

It is important to carry out proper psychosocial assessments and ask appropriate questions to help gather comprehensive information about a patient. This will enable a provider to be in the best position of carrying out the most effective diagnosis for the patient. After developing a diagnosis, courses of actions should then be established. The Cognitive Behavioral Theory approach can be used to help the patient learn how she can cope with her situations and ways of staying away from negative thinking. This approach can enhance her skills of socializing and making new friends so that they can help her to share ideas and gain social skills that she can use in managing social situations to avoid possible anxiety.