Treatment plan

COUN6331 Case Study Treatment Plan

Case Study Treatment Plan

Keisha Henry

COUN 6311

November 10th , 2019

Mental Health Counseling Clinical Internship 1

Case Study Treatment Plan

Section 1: Identifying Information

Counselor assessed the client Stella in a face to face interview on November 3, 2019 to do a complete mental status examination and substance evaluation. Stella case was reviewed in staffing on November 4, 2019. Stella is a 38 years old biracial female who is of African American and Native American decent. Stella was adopted as an infant by a Caucasian Couple in a closed adoption. Stella’s adopted parents are deceased and has no way of finding her birth parents. Stella is unable to give any family history due to lack of knowledge of her birth parents. Stella only was able to share that her mom was a teen who was raped. Stella has been married for 18 years and has one son who is a junior in high school. Stella is employed full-time as a book-keeper for a local meat packing company but prior to this job she has had trouble keeping a job for more than a few months due to her mood changes. Stella has an associate’s degree in accounting and certified as a tax prepare. Stella husband is a long-distance truck driver. Stella identified being Catholic but does not attend church often. Stella living environment is stable. Stella was cooperative, calm and willing to share during the assessment and maintained good eye contact and able to express her thoughts and feelings. Stella dress was neat and clean and her affect was appropriate. Stella denied being suicidal or homicidal presently. Stella has a history of suicidal attempts, unstable mood, marijuana use. Stella also often described her depressed mood as feeling “blue”.

Section 2: Presenting Problem

In the case of Stella, she has a number of presenting problems. Presently Stella has been referred to Stages Mental Health Clinic to continue care after recent discharge from the hospital due to increased symptoms of depression as evident by her sobbing uncontrollably at work and expressing she was “blue”. Stella admitted herself in the hospital because of decompensation. Stella have been non-compliant with treatment and her mood was unstable prior to hospitalization which occurred after her counselor moved and closed her practice and Stella did not follow-up when she was referred to another agency. Stella most often reports feeling “blue” but, when she describes being happier she displays a number of irrational behaviors such as excessive spending. Stella was able to express a want to not feel “blue”. Stella also utilizes marijuana when she is not taking her medication. Stella has a history of mental health problems starting as an adolescent and has continued over the years. Stella started to see a counselor as a teen after a suicide attempt but once she did not feel depressed anymore she stopped treatment. Stella in her early 20’s she attempted suicide at work which led to an inpatient hospitalization at that time she expressed that episode of feeling “blue” was the worst but once she was but on medication for her depression her mood changed and Stella became hypersexual as evident by her sleeping with strangers when her husband was traveling, she displayed excessive spending, unable to complete task at job, drinking alcohol uncontrollably and smoking marijuana. Her behaviors prompted her husband to take her back to the psychiatrist and he added a mood stabilizer medication. Due to non-compliance with medication client mood has been difficult to stabilize

Section 3: Previous Treatments

Stella has a history of mental health treatment starting as an adolescent and has continued over the years. Stella has been hospitalized for mental health treatment three times. Two of Stella’ hospitalizations occurred due to suicidal attempts and the last hospitalization was a voluntary admit because of her severe symptoms which including excessive sobbing, lack of motivation, and poor self-worth. Stella has been also counseling and she has been prescribed medication to help with the stabilization of her mood. Stella has shown progress when she is compliant with medication and when she utilizes counseling effectively.

Section 4: Strengths, Weaknesses, and Support Systems

· Stella’s strengths include being motivated for treatment, and she displayed good insight as it relates to symptomology and verbally able to express her needs. Stella is able to express herself verbally and displays the ability to communicate her needs effectively.

· Stella’s weakness is that once she starts to feel better as it related to her mood she starts to taking her medication and she stop attend counseling. Client lacks knowledge of family history due to being adopted.

· Stella has a very supportive husband, son and sister-in-law.

· It has been found that Negative outcomes have a direct correlation to co-occurrence of mental disorders mixed with substance abuse disorders and this a difficult for recovery for the client (Najt et. al, 2011). There is also a high co-occurrence between cannabis use and cannabis use disorder associated with both Major depression and Bipolar disorder which are two major diagnoses within the mood disorder (Taub, S., et. al., 2018). It was found that most individuals that was diagnosed with bipolar disorder used cannabis as a way to self-medicate and cannabis is not showing causes decompensation (Taub, S., et. al., 2018).

· Stella compliance with treatment is imperative to Stella’s success. The key factor that will impact the client’s progress is the client identify the goal for treatment and also reviewing the client progress toward her goal and also make changes if you needed.

Section 5: Assessment

There are many assessment tools available to clinicians. The American Counseling Association, (2014) code of ethics explains that the primary reason for the assessment is to collect information from the client has a number of different purposes which including, but not limited to, client ability to make decisions, treatment planning, forensic proceedings and they can include both qualitative and quantitative methodologies. It is the clinician’s job to select the assessment tool that best fits the client. In choosing an assessment tool one must identify what needs to be assessed to appropriately identify the problem. The Biopsychosocial Assessment and the Mood Disorder Questionnaire (MDQ).

The strengths of Biopsychosocial assessment allow the clinician to look at different aspects of the client’s life, which included family history, presenting events, review of records obtained from other facilities, the clients level of support and improved the clinician understanding of what the client’s expectations are and the information obtained allowed the primary clinician to evaluate the severity of the client’s symptoms. The MDQ is a self-report form with 13 questions plus items assessing the clustering of symptoms and functional impairments and it was shown to have a low sensitivity. These tools will allow the counselor to collect data properly and assist in the appropriate diagnoses (Baldassano, C. F. ,2005). The assessment tools utilized in this process is important due to the fact that the possibility of misdiagnosing the client because of this the clinician use the DSM-5 Handbook of Differential Diagnoses to assist with avoiding misdiagnoses of Stella.

Section 6: Diagnosis

The diagnosis that has been determined after reviewing Stella’s assessment is Bipolar II disorder. Stella symptoms that she has experienced since an adolescent she has had 3 suicidal attempts, she feels depressed most of the time, she wants to sleep often, she has difficulty focusing, she has had one hypomanic episode, she lacks self-worth to name a few. Client meet the diagnostic criteria for Bipolar II DISORDER current episode depressed moderate severity 296.89 (F31.81).

References

ACA, (2014). American Counseling Association Code of Ethics. Alexandria,Va: Author

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC.

Baldassano, C. F. (2005). Assessment tools for screening and monitoring bipolar

disorder Blackwell Publishing. doi:10.1111/j.1399-5618.2005.00189.x

Taub, S., Feingold, D., Rehm, J., & Lev-Ran, S. (2018). Patterns of cannabis use and

clinical correlates among individuals with major depressive disorder and bipolar

disorder. Comprehensive Psychiatry, 80, 89-96. doi:10.1016/j.comppsych.2017.09.004

Naji, Pablo, Poli-Fusar, Paolo, & Brambilla, Paolo. (2011). Co-occurring mental and

substance abuse disorders: A review on the potential predictors and clinical outcomes.

Psychiatry Research. 186(2).159-164.

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