Initial treatment Plan-Eliza

           A psychological assessment is a thorough and comprehensive evaluation of individuals seeking health services on their mental, emotional, and physical health as well as how they perceive themselves and their capability to interact and work well in the community. The evaluation process requires expertise, which then makes it necessary to performed by a professional to enable them to gain more understanding about the condition of the patient and will allow them to determine their present and future behavior (Waugh et al., 2017). It is one of the crucial processes in health care because of its abilities to enable the health care team to develop an individualized care plan that will provide instruction on how the client will be managed, including all actions that are required. The whole process is carried out by the use of question and answer strategy in which the client is expected to provide honest answers. However, questions that clients are asked depends on the conditions/state of the patient during the visit to the health facility (Waugh et al., 2017). The information provided by the client is usually gathered by the therapist and later used to develop a health care plan that will be used to manage the patient. This paper will discuss all processes from the assessment of the patient to the development of the treatment plan.

Part 1: Intake

           Eliza is an 18-year-old female student and a Caucasian client who studies at the City University. During the first session, the therapist offered her intake form to fill. Unfortunately, the client was not willing to offer complete info, which could be used to come up with an effective treatment care strategy. However, from the little information she provided, she claimed to have low self-esteem with experiences of anxiety and stress. Furthermore, she disclosed that the relationship between her and her mother, working as a secretary in the elementary school, was good. She further indicates that her treatment process was not voluntary. 

           Since the information provided was little, the therapist asked her to fill a cross-cutting measure (CCM) 1. This was to ensure that the psychological assessment process was complete. The responses provided by the client in cross-cutting measure 1 would function as a screening tool, and that would aid the provider later in facilitating the identification of symptom-specific diagnosis (Black & Grant, 2014). The completed CCM-1 shows she had experienced mild anxiety, which then required her to fill PROMIS Diagnostic and Statistical Manual of Mental Disorders fifth edition Level 2-Anxiety for an adult.

           However, to facilitate a complete assessment, the health provider needed the parents of the client, both Burt, and Joan, to help in filling the Personality Inventory for Diagnostic and Statistical Manual of Mental Disorders fifth edition –Informant Form (PID-5-IRF)-Adult. Due to the fact that the patient was not willing to provide enough info that was crucial together with the not observing to attend to the treatment on free will, the therapist believes that her parents will play a significant role in facilitating understanding precisely. Besides, she was experiencing challenges in school.

           At the end of the assessment process, the health provider will be able to determine the clients manifesting concerns. Further, after identifying the problem, a collaborative approach will be used by both the client and the therapist to come up with goals that can be attained and then consider it in developing a treatment care plan that is effective (Waugh et al., 2017). The client, together with the counselor, will also be able to discuss and identify various possible interventions and later choose the most appropriate and effective one to implement. Also, the assessment will provide methods that can be used to evaluate the effectiveness of the strategy utilized, which then will provide feedback that facilitate decision making concerning the care.

Part 2: Biopsychological Assessment

           Eliza is an 18year-old female student and Caucasian client from City University who was referred to the facility to look for health services. This occurred after she was caught on her campus, dormitory consuming alcohol. However, the client denied the claims that she was intoxicated. According to her, she was drinking alcohol because her friends were also doing the same; thus, she never saw it as something substantial or something that required attention.

           Moreover, she indicated her school as a life-stressor. Also, she states that she assumed college would not have a lot of work as it is, which is different from her form of high school. The client now reports that the college work has overwhelmed her and also admits that she has challenges putting up with it. From this, it is clear that transitioning from high school to college was problematic for the client. Besides, the social aspect that is present in college affects her and has the possibility of influencing greatly on her life than the way she admits herself.

           Additionally, the client also believes that she has a valuable social relationship and feels like the friends she associates with taking advantage of her. The client also states that she misses her high school friends. It is necessary to note that the client might be lacking the essential support systems, which might make her current condition more complicated for her or challenging to withstand. Besides, the consumption of alcohol, in this case, it is not a crucial factor. This is because the client admitted that she took them because her friends were also doing the same. Thus, it was a case to fit in the group. Furthermore, the fact that the client was ok with her friends' behavior, and the way they influenced her to consume alcohol indicates that she needed to have friends.

           Eliza also indicated her life experience in high school, which she depicts as an easy one. In this case, the current situation can be associated with the desire to have friends, together with low self-esteem. She also admits being a participant in an internet game, which might indicate that she is an addict of internet service. Besides, she also reveals her poor social relationship between her and her parents, which she also indicates that she is overwhelmed at home because she is the only child that contributed to it. The client also confirms that there is little association with the parents, which is about once a week. On the other hand, she denied the use of alcohol and substance abuse. She also refuses any suicidal thoughts in the past or currently. However, she admits that she had experimented with marijuana, which she did not like.

Diagnosis

           Based on the information offered by Eliza, together with those obtained from the assessment symptoms, some of the possible conditions that the client could be ailing from are a depressive, avoidant personality, mild gambling, and adjustment disorders.

Initial Treatment Goal

           The first primary aim of the treatment process was to support the client in relieving symptoms of anxiety and also to reduce or to help her control her gambling ideations

Treatment Plan

Cognitive Behavior Therapy

CBT can play a significant role in the management of adjustment disorder and depressive disorders. The main aim of the therapy is to reduce symptoms of the condition and to help the client view her current school as non-stressor. This kind of treatment will enable her to keep a record, for example, at the point when she feels anxious or when she thinks that her friends are taking advantage of her (Pilgrim, 2019). From this, the therapist will be able to review the records kept by the client, which will then enable them to come up with better approaches to address the situation.

Psychotherapy

In this type, the client will be taught coping skills to help them manage stress and also practical social skills that will enable her to make friends more easily. It is one of the therapies that have both short and long-term benefits because it focuses on addressing the immediate challenges that are faced by the individual (Pilgrim, 2019). This can include avoidance of personal relationship challenges and stressful situations.

Group Therapies

Group therapy involves bringing together individuals with similar conditions. This will promote a better understanding and will also bring a sense of belonging. Besides, it facilitates the sharing of information among individuals (Pilgrim, 2019). This type will help her id addressing the gambling ideation and will also enhance her social skills. This can be done every week.

Family Counselling

           This can be done twice monthly, and it can help in addressing the challenges she faces with her family. It will also act as an opportunity for the client to inform the parents about the problems she is facing during the adjustment process in the college. Besides, parents will also have a better understanding of the roles in the children's lives and growth.

Part 3: Treatment Planning

           The info offered by the patient and the diagnosis will form the basis for the necessity of finishing the Diagnostic and Statistical Manual of Mental Disorders fifth edition Level 2 cross-cutting measure. This is due to the previous completion of the CCM-1. Besides, she will be required to complete CCM-2 regularly after certain intervals, such as a month to aid in monitoring her symptoms.

Furthermore, it will help in tracking the patient's depressive indicators to facilitate decision making concerning the treatment process. CCM-2 also aids in the assessment of the usefulness of Cognitive Behavioral Therapy. Patient Health Questionnaire (PHQ) can be utilized in the monitoring of the patient’s depressive indicators. The symptoms of the client will help in the identification of the severity of the condition. Moreover, PHQ can be used during intake as well as every session as it is useful because it seeks to find out from the patient the degree and frequency of the indicators. Furthermore, the provider can monitor the treatment process effectiveness through the use of the Hamilton Anxiety Rating Scale (HAM-A).

Part 4: Referral

           The present condition of the client might create a need for referral. This is because of the unusual personality disorder and the patient's psychiatric comorbidity that may need more attention from a specialized nurse. The therapist will enlighten the patient on the need to refer her to more experienced and specialized and requesting her to complete the referral form. However, some of the things to consider include the reputation and availability of the necessary resources at the health facility that the patient will be sent to. After this, the therapist will advise the client to continue utilizing the available treatment methods to monitor the disease progression and effectiveness of the methods used to intervene.

 

 

 

 

 

 

References

Black, D. W., & Grant, J. E. (2014). DSM-5 guidebook: The essential companion to the Diagnostic and statistical manual of mental disorders, fifth edition

Pilgrim, D. (2019). Key concepts in mental health. SAGE Publications Limited.

Waugh, M. H., Hopwood, C. J., Krueger, R. F., Morey, L. C., Pincus, A. L., & Wright, A. G. (2017). Psychological assessment with the DSM–5 Alternative Model for Personality Disorders: Tradition and innovation. Professional Psychology: Research and Practice, 48(2), 79.