Proposed treatment plan summary

cpss420_v2_wk4_elements_of_a_treatment_plan.docx

CPSS/420 v2

Treat Plan Elements and Examples

CPSS/420 v2

Page 2 of 2

$C:\Users\djshirey\OneDrive - University of Phoenix\F_Drive\Style Guides\UPX Logos\Horizontal format\UOPX_Sig_Hor_Black_Medium.png$ Treat Plan Elements and Examples

Treatment plans should always be client driven and treatment team supported. Further they should help the client consider how alcohol or substance abuse is impacting all aspects of your client’s life, including the client’s mental, physical, social, financial and legal histories. This document should be fluid and must be updated as the client’s needs change over time or as goals are met. All treatment plans contain the following elements in a treatment plan.

A Diagnostic Summary

The clinical provider will meet with the client and discuss their alcohol and/or substance use patterns, medical history, mental health disorders and legal issues. Based on these assessments, the provider will summarize the main problems that brought the client in for treatment, and recommendations like medication and behavioral therapy based on acceptable treatment practices and possible facility limitations.

A Problem List

The problem list addresses specific issues that the client wants to target during treatment and a summary of the signs and symptoms that highlight the individual problem(s).

Problem (1): Angel has the inability to reduce or stop alcohol and substance intake. This is evidenced by: Angel having both a DUI and a domestic violence arrest in the past year. This is evidenced by: Angel’s Extensive alcohol use (on average six vodka shooters and a six- pack of beer daily) multiple times per week. This is in conjunction with marijuana usage in the morning and right before he retires for the night.

Goal List

After the client and provider create the problem list, the goal list encourages forward thinking about possible solutions. Goals are brief statements about what the client wants to change.

· Based on the client’s problem list (these should directly relate to the alcohol or substance abuse or fall out from the use)

· Comprehensive (focused on how to replace a harmful behavior with a healthy one)

Examples:

Learn new anger management skills.

Learn how to have difficult discussions with my wife.

Objectives

Goals are things you want to change, while objectives are individual steps you will take to achieve each of those goals. Objectives should be “SMART”:

· Specific

· Measurable (actions that can be seen)

· Attainable (reasonable to achieve within the treatment period)

· Relevant (related to the issues on your problem list)

· Time-limited (have a target date for completion before discharge)

Examples:

Gain new insight in how to live sober by going to group counseling

Find a sponsor for myself at the Dragons Den 12-step meeting

Complete steps 1-4 of Alcoholics Anonymous with my sponsor

Interventions

These are the methods your treatment team will use to help you achieve each of your objectives.

Examples:

1. Problem: Angel has the inability to reduce or stop alcohol and substance intake

2. Goal: Learn new coping skills

3. Objective: Find a sponsor for myself at the Dragons Den 12-step meeting

4. Intervention: Treatment team will provide a pass for the client to attend the Dragon’s Den 12-step meeting, monitor weekly 12-step attendance, and help resolve barriers to attendance, such as providing light rail passes.

Tracking and Evaluating Progress

Your treatment team will keep client treatment notes in your jacket to track your progress and evaluate whether a treatment plan is working. The notes have details about the client’s response to treatment, changes in the client’s condition, and changes or updates to the plan. Charts may also include worksheets that include the clients’ thoughts, feelings, and behaviors or journal entries.

Relapse prevention planning

During treatment planning, your clinician should discuss discharge planning and the creation of a relapse prevention plan. After the client has successfully completed the initial treatment program, the client’s relapse prevention plan may include:

· Maintaining attendance at 12-step meetings

· Starting work with a peer recovery coach

· Beginning Medication Assisted Therapy (MAT) for alcohol use

· Contact my sponsor if I am triggered and have using thoughts

image1.png

ProposedTreatmentPlanSummary.docx

Review the Angel Case Study .

Assume the management team at your facility has asked for your help in preparing a treatment plan for the client in the case study.

Prepare a 1,100 word proposed treatment plan summary, including your ideas for a treatment plan. Refer to the Elements of a Treatment Plan document as you prepare your summary.

Include the following:

· Summary of diagnostic issues

· Problem list

· SMART goals

· Objectives

· Possible interventions

Explain how, as a future case manager, you would track and evaluate progress against the plan.

Include at least 2 references.

cpss420_v2_angel_case_study3.docx

CPSS/420 v2

Angel Case Study

CPSS/420 v2

Page 2 of 2

$C:\Users\djshirey\OneDrive - University of Phoenix\F_Drive\Style Guides\UPX Logos\Horizontal format\UOPX_Sig_Hor_Black_Medium.png$ Angel Case Study

(Anxiety, PTSD, Substance Use Disorder)

Case Study Details

Angel is a 44-year-old separated man who says that his substance dependence and his anxiety disorder both emerged in his early 20’s after joining the army. He says that he started to drink to “feel better” at the NCO club on base when his episodes of anxiety made it hard for him to interact with his peers. He states that his anxiety became extreme after his first deployment to Iraq. He worked as a military police officer and was often exposed to hostile fire as his group supported operations. He also states that alcohol and now cocaine were a part of his dishonorable discharge.

His wife called police after an argument regarding his drinking. He shoved her and police arrested him and charged him with domestic violence (DV). He was required to attend DV classes as well as substance abuse treatment as part of the plea. He further has community service hours (48) and 2 years of probation. You are conducting the intake assessment into your treatment agency.

Angel notes that coming off the cocaine and binge drinking contribute to low mood and increased anxiety, but he has not responded well to referrals to adjunct support services, and past inpatient stays have led to only temporary abstinence. He does not have VA connected benefits and his job as a cook offers no insurance coverage. Yet, Angel is now trying to forge a closer relationship to his adult children, and he says he is especially motivated to get a better handle on both his PTSD and his substance use because he will be a grandfather in January. Angel states he and his wife are currently separated but talk on a daily basis.

Symptoms

· Alcohol Use

· Depression

· Anxiety

· PTSD

· Substance Abuse

Diagnoses and Related Treatments

PTSD

The following treatments have empirical support for individuals with PTSD:

· Cognitive Processing Therapy (CPT)

· Trauma-focused Cognitive Behavioral Therapy (cf-CBT)

· Eye Movement Desensitization and Reprocessing (EMDR)

Mixed Substance Abuse/Dependence

The following treatments have empirical support for individuals with Mixed Substance Abuse/Dependence:

· Motivational Interviewing plus CBT for Mixed Substance Abuse/Dependence

· Seeking Safety for Mixed Substance Abuse/Dependence

· Motivational Enhancement Therapy (MET) for Substance Abuse Treatment

Generalized Anxiety Disorder

The following treatments have empirical support for individuals with Mixed Substance Abuse/Dependence:

· CBT for Generalized Anxiety Disorder

· Psychoeducation

· Mindfulness

Adjunct support services

· AA, NA or other 12-Step program

· SMART recovery

· Peer Recovery Coaching

· Mindfulness Recovery

image1.png

cpss420_v2_wk4_elements_of_a_treatment_plan.docx

CPSS/420 v2

Treat Plan Elements and Examples

CPSS/420 v2

Page 2 of 2

$C:\Users\djshirey\OneDrive - University of Phoenix\F_Drive\Style Guides\UPX Logos\Horizontal format\UOPX_Sig_Hor_Black_Medium.png$ Treat Plan Elements and Examples

Treatment plans should always be client driven and treatment team supported. Further they should help the client consider how alcohol or substance abuse is impacting all aspects of your client’s life, including the client’s mental, physical, social, financial and legal histories. This document should be fluid and must be updated as the client’s needs change over time or as goals are met. All treatment plans contain the following elements in a treatment plan.

A Diagnostic Summary

The clinical provider will meet with the client and discuss their alcohol and/or substance use patterns, medical history, mental health disorders and legal issues. Based on these assessments, the provider will summarize the main problems that brought the client in for treatment, and recommendations like medication and behavioral therapy based on acceptable treatment practices and possible facility limitations.

A Problem List

The problem list addresses specific issues that the client wants to target during treatment and a summary of the signs and symptoms that highlight the individual problem(s).

Problem (1): Angel has the inability to reduce or stop alcohol and substance intake. This is evidenced by: Angel having both a DUI and a domestic violence arrest in the past year. This is evidenced by: Angel’s Extensive alcohol use (on average six vodka shooters and a six- pack of beer daily) multiple times per week. This is in conjunction with marijuana usage in the morning and right before he retires for the night.

Goal List

After the client and provider create the problem list, the goal list encourages forward thinking about possible solutions. Goals are brief statements about what the client wants to change.

· Based on the client’s problem list (these should directly relate to the alcohol or substance abuse or fall out from the use)

· Comprehensive (focused on how to replace a harmful behavior with a healthy one)

Examples:

Learn new anger management skills.

Learn how to have difficult discussions with my wife.

Objectives

Goals are things you want to change, while objectives are individual steps you will take to achieve each of those goals. Objectives should be “SMART”:

· Specific

· Measurable (actions that can be seen)

· Attainable (reasonable to achieve within the treatment period)

· Relevant (related to the issues on your problem list)

· Time-limited (have a target date for completion before discharge)

Examples:

Gain new insight in how to live sober by going to group counseling

Find a sponsor for myself at the Dragons Den 12-step meeting

Complete steps 1-4 of Alcoholics Anonymous with my sponsor

Interventions

These are the methods your treatment team will use to help you achieve each of your objectives.

Examples:

1. Problem: Angel has the inability to reduce or stop alcohol and substance intake

2. Goal: Learn new coping skills

3. Objective: Find a sponsor for myself at the Dragons Den 12-step meeting

4. Intervention: Treatment team will provide a pass for the client to attend the Dragon’s Den 12-step meeting, monitor weekly 12-step attendance, and help resolve barriers to attendance, such as providing light rail passes.

Tracking and Evaluating Progress

Your treatment team will keep client treatment notes in your jacket to track your progress and evaluate whether a treatment plan is working. The notes have details about the client’s response to treatment, changes in the client’s condition, and changes or updates to the plan. Charts may also include worksheets that include the clients’ thoughts, feelings, and behaviors or journal entries.

Relapse prevention planning

During treatment planning, your clinician should discuss discharge planning and the creation of a relapse prevention plan. After the client has successfully completed the initial treatment program, the client’s relapse prevention plan may include:

· Maintaining attendance at 12-step meetings

· Starting work with a peer recovery coach

· Beginning Medication Assisted Therapy (MAT) for alcohol use

· Contact my sponsor if I am triggered and have using thoughts

image1.png

ProposedTreatmentPlanSummary.docx

Review the Angel Case Study .

Assume the management team at your facility has asked for your help in preparing a treatment plan for the client in the case study.

Prepare a 1,100 word proposed treatment plan summary, including your ideas for a treatment plan. Refer to the Elements of a Treatment Plan document as you prepare your summary.

Include the following:

· Summary of diagnostic issues

· Problem list

· SMART goals

· Objectives

· Possible interventions

Explain how, as a future case manager, you would track and evaluate progress against the plan.

Include at least 2 references.

cpss420_v2_angel_case_study3.docx

CPSS/420 v2

Angel Case Study

CPSS/420 v2

Page 2 of 2

$C:\Users\djshirey\OneDrive - University of Phoenix\F_Drive\Style Guides\UPX Logos\Horizontal format\UOPX_Sig_Hor_Black_Medium.png$ Angel Case Study

(Anxiety, PTSD, Substance Use Disorder)

Case Study Details

Angel is a 44-year-old separated man who says that his substance dependence and his anxiety disorder both emerged in his early 20’s after joining the army. He says that he started to drink to “feel better” at the NCO club on base when his episodes of anxiety made it hard for him to interact with his peers. He states that his anxiety became extreme after his first deployment to Iraq. He worked as a military police officer and was often exposed to hostile fire as his group supported operations. He also states that alcohol and now cocaine were a part of his dishonorable discharge.

His wife called police after an argument regarding his drinking. He shoved her and police arrested him and charged him with domestic violence (DV). He was required to attend DV classes as well as substance abuse treatment as part of the plea. He further has community service hours (48) and 2 years of probation. You are conducting the intake assessment into your treatment agency.

Angel notes that coming off the cocaine and binge drinking contribute to low mood and increased anxiety, but he has not responded well to referrals to adjunct support services, and past inpatient stays have led to only temporary abstinence. He does not have VA connected benefits and his job as a cook offers no insurance coverage. Yet, Angel is now trying to forge a closer relationship to his adult children, and he says he is especially motivated to get a better handle on both his PTSD and his substance use because he will be a grandfather in January. Angel states he and his wife are currently separated but talk on a daily basis.

Symptoms

· Alcohol Use

· Depression

· Anxiety

· PTSD

· Substance Abuse

Diagnoses and Related Treatments

PTSD

The following treatments have empirical support for individuals with PTSD:

· Cognitive Processing Therapy (CPT)

· Trauma-focused Cognitive Behavioral Therapy (cf-CBT)

· Eye Movement Desensitization and Reprocessing (EMDR)

Mixed Substance Abuse/Dependence

The following treatments have empirical support for individuals with Mixed Substance Abuse/Dependence:

· Motivational Interviewing plus CBT for Mixed Substance Abuse/Dependence

· Seeking Safety for Mixed Substance Abuse/Dependence

· Motivational Enhancement Therapy (MET) for Substance Abuse Treatment

Generalized Anxiety Disorder

The following treatments have empirical support for individuals with Mixed Substance Abuse/Dependence:

· CBT for Generalized Anxiety Disorder

· Psychoeducation

· Mindfulness

Adjunct support services

· AA, NA or other 12-Step program

· SMART recovery

· Peer Recovery Coaching

· Mindfulness Recovery

image1.png

cpss420_v2_wk4_elements_of_a_treatment_plan.docx

CPSS/420 v2

Treat Plan Elements and Examples

CPSS/420 v2

Page 2 of 2

$C:\Users\djshirey\OneDrive - University of Phoenix\F_Drive\Style Guides\UPX Logos\Horizontal format\UOPX_Sig_Hor_Black_Medium.png$ Treat Plan Elements and Examples

Treatment plans should always be client driven and treatment team supported. Further they should help the client consider how alcohol or substance abuse is impacting all aspects of your client’s life, including the client’s mental, physical, social, financial and legal histories. This document should be fluid and must be updated as the client’s needs change over time or as goals are met. All treatment plans contain the following elements in a treatment plan.

A Diagnostic Summary

The clinical provider will meet with the client and discuss their alcohol and/or substance use patterns, medical history, mental health disorders and legal issues. Based on these assessments, the provider will summarize the main problems that brought the client in for treatment, and recommendations like medication and behavioral therapy based on acceptable treatment practices and possible facility limitations.

A Problem List

The problem list addresses specific issues that the client wants to target during treatment and a summary of the signs and symptoms that highlight the individual problem(s).

Problem (1): Angel has the inability to reduce or stop alcohol and substance intake. This is evidenced by: Angel having both a DUI and a domestic violence arrest in the past year. This is evidenced by: Angel’s Extensive alcohol use (on average six vodka shooters and a six- pack of beer daily) multiple times per week. This is in conjunction with marijuana usage in the morning and right before he retires for the night.

Goal List

After the client and provider create the problem list, the goal list encourages forward thinking about possible solutions. Goals are brief statements about what the client wants to change.

· Based on the client’s problem list (these should directly relate to the alcohol or substance abuse or fall out from the use)

· Comprehensive (focused on how to replace a harmful behavior with a healthy one)

Examples:

Learn new anger management skills.

Learn how to have difficult discussions with my wife.

Objectives

Goals are things you want to change, while objectives are individual steps you will take to achieve each of those goals. Objectives should be “SMART”:

· Specific

· Measurable (actions that can be seen)

· Attainable (reasonable to achieve within the treatment period)

· Relevant (related to the issues on your problem list)

· Time-limited (have a target date for completion before discharge)

Examples:

Gain new insight in how to live sober by going to group counseling

Find a sponsor for myself at the Dragons Den 12-step meeting

Complete steps 1-4 of Alcoholics Anonymous with my sponsor

Interventions

These are the methods your treatment team will use to help you achieve each of your objectives.

Examples:

1. Problem: Angel has the inability to reduce or stop alcohol and substance intake

2. Goal: Learn new coping skills

3. Objective: Find a sponsor for myself at the Dragons Den 12-step meeting

4. Intervention: Treatment team will provide a pass for the client to attend the Dragon’s Den 12-step meeting, monitor weekly 12-step attendance, and help resolve barriers to attendance, such as providing light rail passes.

Tracking and Evaluating Progress

Your treatment team will keep client treatment notes in your jacket to track your progress and evaluate whether a treatment plan is working. The notes have details about the client’s response to treatment, changes in the client’s condition, and changes or updates to the plan. Charts may also include worksheets that include the clients’ thoughts, feelings, and behaviors or journal entries.

Relapse prevention planning

During treatment planning, your clinician should discuss discharge planning and the creation of a relapse prevention plan. After the client has successfully completed the initial treatment program, the client’s relapse prevention plan may include:

· Maintaining attendance at 12-step meetings

· Starting work with a peer recovery coach

· Beginning Medication Assisted Therapy (MAT) for alcohol use

· Contact my sponsor if I am triggered and have using thoughts