Case Study Treatment Plan: Treatment Goals

Open Posted By: highheaven1 Date: 01/03/2021 High School Assignment Writing

For this assignment, you will submit additional components of your treatment plan based on the case study you selected. You can view the case studies in the Case Study Treatment Plan multimedia piece, available in the Resources. Complete the following components of the Case Study Treatment Plan Template:

  • Treatment plan literature review.
  • Goals and interventions.
  • Communication with other professionals.
  • Medications.
  • Legal, ethical, and other considerations.
  • References.

The sections of your treatment plan for this assignment should be 4–6 pages in length and include a minimum of four references from the current professional literature in counseling. Be sure to cite your references in current APA format.

Please continue to use the Case Study Treatment Plan Template to organize your work. Each section of the template includes a description of the type of information you need to include.

In the template for this assignment, also include the treatment plan components you wrote for the Unit 5 assignment so your instructor can refer to the previous information you provided about this client's case when reviewing the components you have added for this assignment. When your template is complete, save it as a Word document with your name and submit it to the assignment area.

Category: Engineering & Sciences Subjects: Electrical Engineering Deadline: 24 Hours Budget: $80 - $120 Pages: 2-3 Pages (Short Assignment)

Attachment 1


Case Study Treatment Plan: Assessment Process

FirstName LastName

University title



Case Study Treatment Plan

Section 1: Identifying Client Information

My client goes by the name Stella. She was born thirty-eight years ago by parents from

different ethnicity. The mother was of African American race, while her male parent was

Caucasian. Her biological parents did not raise Stella. She was brought up by an adopted

parent who took care of her right from the youngest age and adolescence. She was lucky to

have a supportive parent because she took good care of her in all dimensions. For example,

the foster mother ensured that Stella was healthy and acquired high school and college

education levels. Unfortunately, her parent died, and she has nobody she can call mother or

father, especially when she is faced with difficulties.

Stella has been in a marriage relationship for one decade and eight years. She is married to

Doug, a man who works in the transportation industry as a driver and spends most of his time

on the road than the period she spends home with his wife, Stella. However, for the past

eighteen years, the two have no child of their own. Presently, Stella works as a book keeper

in a firm that specializes in packing. Apart from working at this firm, Stella has worked in

various organizations, although her stays were short-lived. Stella has a strong educational

background. She went through high school education, later joined a community college

where she pursued an associate degree that has remained steadfast in defining her career


However, it is worth noting that Stella originates from a disadvantaged background that

contributed enormously to a series of trouble she has endured right from her childhood to

adulthood. For example, being a product of an interracial relationship, Stella has hard identity

issues finding her space in her society. Also, being raised by foster hands, weight problems,

marital challenges, and drug addiction are some of the setbacks that subjected Stella to a

problematic life both at home and workplace.



Section 2: Presenting Issues and Concerns

Over time, Stella has undergone a series of agonies. Her journey has not been easy,

considering the list of challenges she has ensured in the last 38 years. Honestly, Stella’s

mental health has never been good. She has experienced many struggles that have

destabilized her mental health and subject her to unending miseries such as depression and

other mental troubles. First, Stella is not connected to her biological mother and father, a

phenomenon that is not always easy for anyone to cope up with. Another challenge is being

childless despite being in a marriage relationship for nearly two decades. Maria has always

wanted a baby, but she cannot conceive or carry a pregnancy. Third, Stella is not a happy

person in marriage. She is almost married to herself, bearing that her husband spends most of

his time on the road. She complained that she has become a lonely human being because the

husband stays home for not more than half a week and goes away for over fourteen days.

Fourth, her past is characterized by mood issues. Stella reports experiencing negative moods

in most of her life because she had no friends and families to share. Fifth, overweight is a

condition that subjected Stella to trauma. She felt unattractive on several occasions, a

situation that had destructive implications on her self-esteem and socialization. Also, Stella

has a bad history of drug addiction, which is drinking in excess and misusing hard drugs such

as Marijuana. Indeed, the continued use of drugs subjected Stella to numerous miseries and

behaviors such as extravagance and carelessness. Lastly, Stella has tried taking her life

severally, a phenomenon that was fueled by depression.

Presently, Stella has improved her situation, and she is looking forward to living a happier

life. However, she has veracious concerns that can be solved or managed through counseling.

Firstly, she is concerned about her medication. Stella is worried about maintaining it, and she

needs assistance on how she can stick to her medication to save her life. She is optimistic

about the new medication; she needs time to time help on various ways of maintaining the



new medication so that she does not get back to her previous condition. Second, Stella is

concerned about her previous habits of drinking and smoking. Despite being positive about

avoiding alcohol and bhang, it is a tough step requiring assistance and commitment. Hence,

the counselor must come in and guide her on the most excellent techniques that will ensure

she does not get back to alcoholism and smoking. Stella has declared that she does not intend

to use any of it; hence, this can only be possible with counselor's help. Third, Stella is

concerned about the absence of a child in her marriage and the loneliness she endures every

day whenever her husband is in transit. Thus, as Stella’s counselor, it is prudent to take her

through sessions that will reinstate her mood, happiness and end the depression she has

suffered for the longest time.

Section 3: Previous Treatments

Stella has attended different treatment experiences. She was recently hospitalized in a

psychiatric healthcare facility where she received mental health care and discharged after a

week. Her stay at the hospital was fundamental in reinstating her mood and eliminating the

possible threats that would subject her to depression. Also, Stella was introduced to the new

medication at this facility, which is promising to work effectively with her situation.

Previously, Stella has received numerous treatments in different stages of life. For example,

she has ever been rushed to emergency services after she attempted killing herself by taking

twenty-five aspirins. She was also introduced to a counselor to help with her situation. Also,

she was hospitalized after the second suicide attempt. Stella stayed at the hospital for about

four days, and she was introduced to a psychiatrist after she was discharged from the facility.

The psychiatrist advised Stella to use SSR and seek counseling services, especially from

those who had assisted her before. At some point, Stella’s spouse has taken her to a

psychiatry facility to seek better medication for her condition.

Section 4: Strengths and Challenges



First, Stella’s strength is her ability to survive through stressful experiences. For the last

thirty-eight years, she has managed to thrive despite the tough and harsh conditions in the

school, home and workplace. Also, self-awareness is Stella’s pillar of her strengths. Stella is

cognizant of her mental health problem, and she is always mindful of seeking assistance in

various capacities. For example, when she wanted to end her life with the twenty-five

aspirins, she quickly sought help from her mother that later took her to emergency services.

Another area of Stella’s strength is her ability to cooperate with counselors. It is evident from

her background and history that she has never resisted counseling sessions or being admitted

to a hospital. Stella’s biggest limitation is her inability to adapt to situations. For instance,

Stella suffers from depression because of her husband spending much time away from home.

She should adapt to the fact that her husband will be at home only for a few days. Stella has a

wide array of support systems right from family (husband and sister in law) and workplace


Section 5: Assessment Processes

According to Bernstein (2016), assessment is a crucial phase in managing and treating mental

health disorders. The authors reveal that counselors utilize these sessions to single out

problems that deter clients' mental health. Hence, conducting an assessment procedure will be

vital in helping Stella recover her mental health. For this case, the counselor will use

structured interviews to conduct a successful assessment process and collect Stella's helpful

information (client). Vacc & Juhnke (2017) put forward that structured interviews are

excellent techniques for carrying out an assessment process because they help the counselor

gather rich, in-depth and contextual information. Therefore, it is the best selection for Stella’s

case due to its effectiveness in gathering vital data from client (Stella). Lastly, the counselor

will utilize Diagnostic reliability to select the most accurate DSM diagnosis for Stella’s case.

Section 6: Diagnosis



Clark, Cuthbert, Lewis-Fernández, Narrow & Reed (2017) say that DSM-5 is a diagnostic

criterion that allows counselors to diagnose and identify the signs and narrow down on the

exact mental disorder destabilizing the mental health of a client. Hence, this mechanism will

ensure that Stella’s situation is effectively diagnosed and possible medication is applied to

save her from agony. The counselor will adhere to the DSM-5 differential steps to identify

the correct disorder hindering Stella from experiencing healthier mental health (First, 2014).


Bernstein, K. S. (2016). Clinical assessment and management of depression. Medsurg

Nursing, 15(6), 333.

Clark, L. A., Cuthbert, B., Lewis-Fernández, R., Narrow, W. E., & Reed, G. M. (2017).

Three approaches to understanding and classifying mental disorder: ICD-11, DSM-5, and the

National Institute of Mental Health’s Research Domain Criteria (RDoC). Psychological

Science in the Public Interest, 18(2), 72-145.

First, M. B. (2014). DSM-5 handbook of differential diagnosis. USA: American psychitric


Vacc, N. A., & Juhnke, G. A. (2017). The use of structured clinical interviews for assessment

in counseling. Journal of Counseling & Development, 75(6), 470-480.

Attachment 2

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P r i n t


INTRODUCTION For your course project, you will develop a treatment plan for one case study subject that you select from two possible candidates. These potential clients are ethnically diverse and are struggling with psychological disorders, which may require medication.

During the course of this project you will:

Organize and present relevant client information.

Review possible assessment techniques.

O�er a diagnostic impression.

Evaluate e�ective approaches and interventions.

Discuss legal and ethical considerations.

Consider methods for e�ective collaboration with members of treatment teams.

Review the impact of diversity issues in assessment and goal formulation.

Develop a suggested treatment plan for the client.

You will select one of the two case studies presented on the next page of this presentation as your client for this treatment plan project. You will write the sections of your assignments directly into the “Case Study Treatment Plan Template” located in the Resources area of each assignment.

STELLA'S CASE STUDY Stella is a 38 year old woman who has just been assigned to you as a client. You are currently working as a counselor for your county community mental health agency that has a contract to provide continuing treatment for patients who have just been discharged from a local psychiatric facility. Stella was discharged last week after a 7 day hospitalization. You received the following information about her as background and history.

Stella is the only child of a Caucasian couple who are now deceased. She was adopted by this couple as an infant in a closed adoption, so that very little information about her parents has been made available to her beyond a birth record noting her mother was African American and her father was Caucasian; both are listed as being 16 years old.

Stella currently lives in a small city of 150,000 people where she is employed as a book-keeper for the local produce packing plant. She has worked there for 3 years. Her educational background includes an associate's degree in accounting and continuing education in tax preparation. Before working for this plant, she was employed as a tax preparer for a national company. She enjoys her work, saying that numbers are easier to get along with than people.

She has been married to her husband (Doug) for 18 years. They have no children due to medical issues that Stella reports have made it very di�cult to get pregnant and carry a child to term. Her husband is a long distance truck driver. He is often away from home for two weeks at a time. He is then at home for only 4 or 5

C r e d i t s

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days before he leaves on another trip. Stella reports that she feels “lonely and blue” when her husband is away. She �nds it di�cult to motivate herself to do anything when he is on the road beyond going to work and coming home. She has few friends beyond acquaintances at work and only occasionally participates in activities at her local church.

Stella reported that her problems began when she was in early adolescence. She started sleeping and eating excessively. She missed many days of school because she couldn't get out of bed and gained 25 lbs. over the course of 2 years. Because Stella felt unattractive due to the weight gain she experienced, she obtained some methamphetamines from a friend of hers in school so she could lose the weight quickly. She was able to do so, but found that when she stopped taking the pills she felt even lower than before. She asked her friend for more pills, but her friend refused to provide them. Stella's mood continued to decline; she believed she was a failure, that she would never be successful at anything, and stopped talking to her friends. She stated that she felt "blue" during this time, a word she frequently uses to describe her mood. This episode lasted about one month until school ended for the summer. During the summer, she felt better because she had a summer job as a stocker at the local grocery store where she became involved with a boy from a local school. The following year, she once again became "blue" and this time she took 25 aspirins in a suicide attempt. She panicked and told her mother, who took her to the emergency room to have her stomach pumped. Stella started to see a counselor after this incident, but when she began to feel better, she stopped her counseling.

Stella was able to successfully graduate from high school and earn an associate's degree at the local community college. Her �rst full-time job was back at the grocery store, where she worked in the o�ce preparing bank deposits and reconciling bank statements. She reported that she enjoyed this job and felt better about herself. She reconnected with her previous boyfriend and they married. However, after 3 years, she again experienced depression, this time more severely than ever before. "It felt like my 'blue' had taken over my whole world and I couldn't see anything else. I just wanted to die. That had to be better than how I was feeling." Her suicide attempt this time was more serious; she cut her wrist in the bathroom at work. A co- worker found her and called 911. She spent four days in the hospital and was referred to a psychiatrist for follow-up care. The psychiatrist prescribed an SSRI for the depression and referred Stella to her previous counselor.

Stella began to feel much happier and energized. She made some new friends who liked to “party” – and was out most nights when her husband was away. She drank excessively at night and then smoked marijuana during the day to “take the edge o� and calm down.” She also spent money on new clothes, until she had maxed out her credit cards and borrowed money from her parents. Her performance at work became erratic and her employer began to suspect that money was missing. He was unable to prove the missing money, but became so uncomfortable with Stella's change in behavior and her deteriorating performance that he let her go. Stella was devastated. When her husband returned home, he took her to her psychiatrist, who made adjustments to her medication regime, adding a mood stabilizer. Stella improved over the next several weeks, but was not fully compliant with taking her medications and continued to smoke marijuana from time to time.

Since that time, Stella has had a series of jobs, most of which she was able to keep for several months and, on one occasion, for over a year, until her mood changed and she either “acted out” or became too “blue” to function e�ectively. She feels very fortunate to have kept her current job for so long. She attributes this to a "kind boss," who has kept her employed through her highs and lows. Her boss has asked her to continue with treatment on a consistent basis and since being employed there, she has managed to stay on her medications. Recently, though, her counselor closed his practice and moved to another city. She was distraught by this and refused to �nd another counselor. Gradually, her behavior and mood became more and more unstable over time.

This most recent hospitalization came after she was found at her work desk, sobbing uncontrollably and saying she wanted to die. The work site placed her on medical leave and required her to get treatment before she could return. Stella admitted herself to the hospital, where she saw a new psychiatrist, who changed her medications. She stayed in the hospital for 7 days until her mood stabilized and she was no longer considered to be a threat to herself. Stella is positive that she will be able to stay on the new medications and that she

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does not plan to drink or use any drugs. She has asked for a report of her progress to be given to her employer so she can go back to work as soon as possible.

Her husband is very supportive of her getting care and has met with both the new psychiatrist and your agency’s intake case worker. He reported that his sister has volunteered to go walking with Stella each day when he is out of town and will help her manage her medication. His sister has a 5 year old daughter whom Stella adores and he thinks being around the child will cheer her up.

You will now be Stella’s counselor. After reviewing her hospital records and the intake report, you are ready to begin developing a preliminary treatment plan that will address, among other issues, medication and treatment compliance, and stabilization. You have spoken with Stella brie�y by phone and plan to meet with her next week.

OSCAR'S CASE STUDY Oscar is a 19-year-old Hispanic male who is the oldest of 5 children. His family has been successfully farming the same land for 4 generations. Currently they grow vegetables for a regional grocery chain's produce departments. They live in a rural area of the county. Three generations live in two separate houses on their land. They are very independent and have little to do with people in town, although the family itself is extremely close knit.

Oscar is currently a freshman at a 4-year college located 6 hours away. He is the �rst person in his family to attend college and plans to major in agriculture. He has been living away from home for the past 9 months. At �rst, he had a very di�cult time being away from his family; but as the weeks passed he made fewer and fewer phone calls home and gradually stopped returning calls or emails. When he came home for spring break, his parents noticed signi�cant changes in his appearance. He had lost weight, looked haggard, wasn't sleeping and seemed irritable and argumentative. He told his parents that he was not going to return to college after the break. He went on to say that his roommate had placed cameras in the room so he could record everything Oscar did while the roommate was absent and that he believed the roommate was posting embarrassing videos of him on the internet. His grades were poor and he expressed that he believed his instructors were prejudiced against him. This poor performance was in stark contrast to his performance in high school, where he was in the top 10% of his class. Within days of coming home he had stopped showering and began wearing multiple layers of clothes (3 pairs of jeans and 4 t-shirts). He responded to questions with one word answers and not initiating conversation. Oscar seemed unhappy or irritable whenever he encountered a member of his family and began spending all his time in his room. He even refused to talk with his youngest brother, with whom he had always been close. He did not take meals with his family, a long- standing tradition in his family, and left his room only in the middle of the night. He could then be heard opening drawers in the kitchen, wandering around the halls, and leaving the house for long periods of time.

The family (parents and grandparents) became very disturbed and consulted their priest. The priest recommended that the parents take Oscar to see a fellow parishioner who is also a counselor. Oscar reluctantly accompanied them to the meeting. The counselor was disturbed with Oscar's presentation and recommended hospitalization. The family was very reluctant to do this, but eventually agreed. By the time they got to the hospital, Oscar was essentially non-communicative, staring o� into space and only nodding or shaking his head in response to direct questions.

The psychiatrist diagnosed Oscar with major depressive disorder, single episode, severe with psychotic features and prescribed anti-depressants. He was released two weeks later, with some improvement. Within three weeks, he was readmitted, with the same presentation he had at the previous admission. This time, though, his father reported that he had discovered a container with marijuana hidden in the barn, and also discovered several large knives that Oscar had collected from the house and storage shed on the property. When he asked Oscar about them, Oscar denied that the marijuana was his and responded that he needed the knives to protect himself from attacks. When his father asked from whom, Oscar responded that he had

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seen one of his college professors driving past the house and believed he was spying on him. That same day, Oscar's mother found notes stu�ed under Oscar's mattress in Oscar's handwriting that had drawings of knives and referred to sacri�ces he would need to make in order to keep himself safe. In light of these two events, both parents were afraid for Oscar to remain at the house.

Once Oscar was restabilized at the hospital, he was more forthcoming with his treatment team. Oscar acknowledged that his problems began after a semester of being away from home. He was unable to understand or complete his school work, as he was "consumed" with a buzzing in his head, which soon evolved into whispered words warning him of danger. He tried to keep these voices quiet by buying marijuana from his roommate and smoking on a daily basis. While this helped in the short term, it also made it more di�cult for him to complete any of his school work. He started skipping class and staying in his room most of the time. His roommate and other students on the �oor started making fun of him, which increased his distrust and isolation. By the time of spring break, the voices in his head had begun to change and warned him to trust no one, speak to no one, and arm himself for a possible attack.

The family was brought in for several sessions with Oscar and his therapists and during one meeting they discussed a grandparent on the mother’s side who had exhibited similar symptoms. The family sometimes brought their Priest with them to sessions and requested that prayer be included as an active part of Oscar’s healing.

As Oscar began to show some improvement with continual adjustments to his medication, individual therapy and group therapy, his parents and grandparents wanted to take him home, saying they were in the best position to watch over his care. However, after Oscar experienced a setback where he became increasingly moody and referred to one of the sta� as “a dark force in the building,” they agreed to place him in a residential treatment facility that specializes in working with adolescents and young adults. Although most patients stay in this facility for 6 – 9 months, the family only agreed to a trial of 30 days and said they would still consider taking Oscar home once he had calmed down.

You are working as a counselor at the Residential Treatment facility where Oscar has been placed. He will be there for a minimum of 3 months. Professional sta� at this facility include 3 therapists, an addictions counselor, a social worker who is currently away for an extended leave of absence, a psychologist, and 2 nurses on every shift. Oscar's psychiatrist is also on sta� and will continue to follow his care.

The social worker usually coordinates clients' treatment plans; however since she is currently away, you will be the lead therapist who is coordinating Oscar's treatment during the next 60 days. To prepare for your �rst meeting with Oscar, you will be developing a preliminary treatment plan that summarizes the presenting information, assessments and potential goals.

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