Treatment plan in human services

Sample Presentation

Following is the presentation on Larry McCune by a case manager in the planning conference:

Mr. McCune is a 34-year-old male, an engineer. He came seeking help for symptoms resulting from a severe traffic accident about 4 years ago. He said he was driving and was in the intersection when the light turned red. He was hit and his 4-year-old daughter died in the accident. His marriage broke up about a year ago, and the remaining child, a 9-year-old boy, is currently with the wife.

Mr. McCune complained of severe headaches, and says he has nightmares that involve the accident. He also said he thought he had a phobia (his word) about riding in cars and, more recently, in other forms of transportation. He said he doesn’t feel able to work consistently and talked about being irritable, especially at work.

During the interview, Mr. McCune seemed to have a flat affect and sometimes he was tearful when he discussed the loss of his daughter and later when he was describing the divorce. He seemed to me to have some slowed motor responses. He sat quietly during the interview. He looked sad, and there was no animation in his speech. There were times he appeared not to be focused on the interview.

He is asking for help that will allow him to return to work. He says the two biggest obstacles to that are his problems with transportation and also his irritability with coworkers. I talked to him about the need to find out the origin of the headaches and he agreed with that.

Right now he lives alone. He has stopped attending church, and he said he has few friends. He accepted all my suggestions without much discussion. He seemed pretty passive.

I see this man as depressed and anxious in the sense that he seems to have developed a strong fear about using a car or other transportation. The other impression I had was that he is dealing with a lot of guilt, which he agrees needs to be addressed too. I am recommending that he be evaluated for any residual neurological problems resulting from the accident, just to check on the headaches, and I would like to have him evaluated for depression and possible antidepressant medication. He asked specifically for counseling, and I recommend that. I think he could benefit from that. Mr. McCune might actually benefit from a grief-support group in time. His goal for coming, he told me, is to get back to feeling better and being able to work consistently. Does anyone have any questions?

In this presentation, the case manager has briefly addressed all five parts of the presentation. Others at the meeting might want additional information. For example, someone might ask this case manager about the client’s relationship with the wife and son. Here is how the case manager might answer that question:

We really only talked about that a little bit. He pays support but not consistently. He said his ex-wife is working. He did say he sees his son, but I understood that this is not like a regular visitation schedule or anything. He doesn’t describe the relationship with his ex-wife as extremely hostile. My understanding was that she left because she couldn’t take his irritability and not going to work regularly.

Other issues the team might want to know more about could be whether Mr. McCune expressed a desire to see more of his son; whether he has had any other health issues or health issues related specifically to the accident besides the headaches; what kind of engineering does he do; what has the response been from his employer to his inconsistent work habits; and what living arrangements he has now since his wife and son have moved out.

Follow-Up to Meeting

After the treatment planning conference or disposition meeting, you will write up a formal service plan for your client using the “Treatment or Goal Plan” form we looked at in Chapter 20. When your goal plan is completed, you will:

1. Meet with the individual and discuss the plan: Your first contact note, for our purposes in the classroom, should be written on your first meeting with the person after developing the goals and referral options and having those confirmed in the treatment planning conference or disposition meeting. At this meeting, you will go over the plan with the client, or the client’s parents in the case of a child, and note their response and any changes you make to the plan as a result. When you and the individual feel comfortable with what is planned, you can move on to referring the person to the place where he will receive the treatment or service. In Mr. McCune’s case, he will probably be seen by a neurologist for evaluation of his headaches, by a psychiatrist for evaluation of his depression and possible medication, and by a counselor at a counseling service to work on issues of guilt and loss.

2. Make referrals for your client to the agencies that will actually carry out the services. This happens when your agency does not give services directly.