Treatment PlanBased on the information collected in We.docx
1. Treatment Plan
Based on the information collected in Week 4, complete the
following treatment plan for your client Eliza. Be sure to
include a description of the problem, goals, objectives, and
interventions. Remember to incorporate the client's strengths
and support system in the treatment plan.
Client: ____________________________________________
Date: ______________ Age:______ DOB:
__________________
DSM Diagnosis
ICD Diagnosis
Goals / Objectives:
Interventions:
Frequency:
□ Mood Stabilization
□ Psychotropic Medication Referral & Consultation □
Journaling
□ Cognitive Behavior Therapy □ Skill Training
□ Emotion Recognition – Regulation Techniques
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Anxiety Reduction
□ Psychotropic Medication Referral & Consultation □
Journaling
□ Cognitive Behavior Therapy □ Skill Training
2. □ Relaxation Techniques
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Reduce Obsessive Compulsive Behaviors
□ Psychotropic Medication Referral & Consultation □
Journaling
□ Cognitive Behavior Therapy □ Skill Training
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Decrease Sensitivity to Trauma Experiences
□ Verbalize Memories Triggers & Emotion
□ Desensitize Trauma Triggers and Memories
□ Utilize Healing Model/Support (Mending the Soul)
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Establish and Maintain Eating Disorder Recovery
□ Overcome Denial □ Identify Negative Consequences
□ Menu Planning □ Nutrition Counseling □ Body Image Work
□ Healthy Exercise □ Trigger Mngmt Recovery Plan □ CBT
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Maintain Abstinence from substances (Alcohol/Drugs)
□ Substance Use Assessment □ Stepwork □ Overcome Denial
□ Identify Negative Consequences □ Commitment to Recovery
Program □ Attend Meetings □ Obtain Sponsor
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Increase Coping Skills
□ DBT Skills Training □ Problem Solving Techniques
□ Emotion Recognition & Regulation □ Communication Skills
□ Weekly □ Bi Weekly □ Monthly
3. □ other: ____________________
□ Group □ Individual □ Family
□ Stabilize, Adjustment to New Life Circumstances
□ Alleviate Distress □ Cognitive Behavior Therapy
□ Stress Management □ Skills Training
□ Improve Daily Functioning □ Develop Healthy Support
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Decrease/Eliminate Self Harmful Behaviors
□ Cognitive Behavior Therapy □ Skills Training
□ Develop and Utilize Support System
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Improve Relationships
□ Communication Skills □ Active Listening □ Family Therapy
□ Assertiveness □ Setting Healthy Boundaries
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Improve Self Worth
□ Affirmation Work □ Positive Self Talk □ Skills Training
□ Confidence Building Tasks
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Grief Reduction and Healing from Loss
□ Psychoeducation on Grief Process/ Stages
□ Process Feeling □ Emotion Regulation Techniques
□ Reading/Writing Assignments □ Develop/Utilize Support
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□ Develop Anger Management Skills
□ Decrease Anger Outbursts □ Emotion Regulation Techniques
5. product to develop for the market (Clow & James, 2014).
I would also do data analysis and research to determine our
target market. I would look at the clientele we receive and
identify a common characteristic between them. I would then
ensure that our marketing campaigns were more directed to the
individuals who fell in that bracket. Having a more directed
marketing campaign would ensure that the company used fewer
resources on marketing and would increase sales from
marketing activities (Clow & James, 2014).
I would also analyze the customer feedback and experience after
using the products. This would include the frequency and types
of complaints received, the suggestions given and the number of
customers who returned after purchasing our product. I would
have then relayed this information to the quality control
department to give them pointers on the areas of improvement
needed for the product (Zikmund & Babin, 2007). This would
have greatly helped to increase the sales of the company and
would have made me a valuable asset to the company. The
bottom line is, data analysis and research would have improved
my performance.
References
Clow, K. & James, K. (2014). Essentials of marketing research:
putting research into practice. Thousand Oaks, Calif. London:
SAGE.
Zikmund, W. & Babin, B. (2007). Exploring marketing research.
Mason, OH: Thomson/South-Western.
Psychosocial Assessment
____ Part 1 (Topic 2)
6. Template
____ Part 2 (Topic 3)
Name:
______________________________ Date: _________________
DOB: ________________
Age: ________________________________ Start Time:
____________ End Time: ___________
Identifying Information:
_____________________________________________________
_______________________________ David is a 49 years old
man. He is married with two children. He has been working in a
steel mill as a metallurgical engineer for 20 years.
Presenting Problem:
David has lost interest in doing the things he used to do such as
watching TV, attending family gatherings, and playing golf, and
instead spends a lot of time in his bedroom alone. He has lost
appetite and also doesn’t sleep well. He doesn’t feel the need
for living anymore but believes he will recover from this sour
mood.
Life Stressors:
David’s sister’s condition may have contributed to his condition
since she has been struggling with depression for 10 years.
7. Substance Use: FORMCHECKBOX
Yes FORMCHECKBOX
No
_____________________________________________________
_______________________________ David has had a problem
with alcohol abuse. He drinks more at night because he has
sleep disturbances.
Addictions (i.e., gambling, pornography, video gaming)
David has a problem with alcohol addiction. However, he has
changed his drinking patterns and takes two to three drinks perf
night unlike previously when he used to drink frequently.
Medical/Mental Health Hx/Hospitalizations:
David hasn’t sought help previously from any healthcare
facility in regard to this condition.
Abuse/Trauma:
David doesn’t have major traumatic events. However, Lisa’s
condition may have traumatized him.
Social Relationships:
David has for the last 6 months withdrawn himself from family
gatherings and mostly spends time in solitude.
Family Information:
David has not lost any member of his family. However, losing a
family member can be traumatic and lead to depression.
Spiritual:
David does not give any information about his spiritual
inclinations. However, spirituality can be a cause of mental
8. health problems as well as recovery.
Suicidal:
David admits that he feels that life isn’t worth living.
Therefore, it is most likely he is suffering from depression.
Homicidal:
David does not show any signs of violence towards his friends
and family, or threatening or attempting to kill them.
Name: _____________________________________________
Date: __________________
References
Gore, W. L., & Widiger, T. A. (2013). The DSM-5 dimensional
trait model and five-factor models of general
personality. Journal of abnormal psychology, 122(3), 816. Doi:
org/10.1037/a0032822
Schwitzer, A. M., & Rubin, L. C. (2014). Diagnosis and
treatment planning skills: A popular culture approach (2nd ed.).
Los Angeles, CA: Sage Publications. ISBN-13: 9781483349763
Running head: Depression disorder
1
2
Depression disorder
Screening, Diagnosis and Treatment of Depression Disorder
9. August 6, 2019
Screening, Diagnosis and Treatment of Depression Disorder
Depression is a mental disorder that has both social and
health effects to individuals worldwide. Reports from the WHO
suggest that depressive disorders form a significant percentage
of the total number of deaths reported in both developed and
developing countries. Depressive disorders are also a major
cause of disability (U.S. Department of Health, 2017).
Depression is treatable. The commonly used treatments of
depression include psychotherapy and drugs. Studies suggest
that there are various effective strategies available for use to
improve the depression symptoms such as the integration
between specialist and primary health care. The severity of
depression varies from patient to patient. DSM-5 is the
commonly used diagnostic criteria used to differentiate
depressive disorders from sadness (Gore & Widiger, 2013). The
criterion was developed in the United States and has been used
extensively in psychiatric research. The model stipulates the
threshold that the signs and symptoms of depression must meet
to justify a diagnosis. This research analyzes Eliza Doolittle’s
psychosocial assessment and treatment plan.
Intake
Eliza Doolittle is an eighteen years old girl. Her residence at the
time of the visit was a school dormitory where she lived with
her friends. Eliza stated the reason for her visit was due to
being sent home from school. The depressive symptoms that
Eliza experienced were anxiety or stress and low self-esteem.
Eliza is the only child in her family. Her father is Burt, and her
mothers name is Joan. She denied being on any medication for
mental health at this time. She also added that she had not
encountered any stressful experiences in her life.
Eliza completed the DSM-5 Self-Rated Level 1 Cross-Cutting
Symptom Measure (CCM-1) for adults, which is a questionnaire
with the various depressive symptoms. This questionnaire
enables the healthcare professional to identify the depressive
10. symptoms that Eliza might have had in the last two weeks
before her visit. According to the DSM-5 diagnostic criteria,
Eliza must have experienced at least five symptoms of
depression in the same two weeks period. Eliza must have at
least one of the following symptoms to warrant a diagnosis.
These include: loss of pleasure in usual activities, loss of self-
worth or suicidal, fatigue, weight loss, tiredness, inability to
think correctly, loss of energy and loss of appetite.
Biopsychosocial Assessment
Eliza was identified as a Caucasian female who was a first-year
college student studying engineering. Eliza’s parents live in a
town, which is about two hours away from the health center.
Eliza was sent to counseling because she was found with
alcohol in the dormitory although she claimed she was not
intoxicated. However, she said that she was drunk. Eliza said
that she had been experiencing stress in school since things in
college were not easy as they were in high school. She added
that study requirements have been difficult in college. Eliza
stated that making friends had been difficult for her since her
high school friends either went to different colleges or pursued
other things.
Eliza admitted that she had used substances such as alcohol, and
marijuana, although she said that she has never overused any of
the substances. The only type of addiction that Eliza has was
online gaming. Besides, she denied having been previously
hospitalized due to mental illness. Eliza has had traumatic
experiences, although she stated that she was teased in high
school. Eliza’s social relationships were questionable because
she felt that her friends were misusing her on many occasions.
However, she had a good relationship with her parents despite
there being some strains between the parents. Her family rarely
goes to church; therefore, she is not strictly spiritually aligned.
Eliza denied having had suicidal or homicidal intentions.
Assessment of Eliza’s symptoms using the DSM-5 diagnostic
criteria showed that Eliza had experienced five depressive
symptoms in the last two weeks prior to her visit to counseling.
11. The symptoms included little pleasure or interest in doing
normal activities, anxiety, slight sleeping problems, lack of
identity, and little enjoyment of social activities. The CCM-1
results show that Eliza has slight symptoms of depression,
which if not managed, can easily become more severe if the
causes are not well managed. According to the DSM-5
diagnostic criteria, the results suggest that Eliza has mild
depression because she had experienced at least one diagnostic
symptom that is a loss of pleasure in usual activities.
The initial treatment goals for Eliza would be directed towards
improving the depressive symptoms that Eliza has experienced.
The major depressive symptoms in Eliza’s life are the loss of
interest in normal activities as well as anxiety. There is no
standard treatment for mild depression. However, Eliza has
several options available for her treatment. First, the symptoms
of mild treatment can go away without being treated. The
physician can allow Eliza to go and come back after two weeks
to check whether the situation will have improved (Schwitzer &
Rubin, 2014). This method is commonly referred to as watchful
waiting. Secondly, the physician can advise Eliza to start doing
exercises. Exercise has been identified as one of the effective
methods of dealing with mild depression (Schwitzer & Rubin,
2014). The physician can decide to involve Eliza in a group
class where they will be doing exercises together. Third, self-
help is a method of treating mild depression where Eliza would
think about her feelings by talking to a psychological therapist
or a friend.
Treatment Planning
APA offers a number of measures that help in the
assessment of patients. The assessment measures should be
administered form the first interview with the patient to help
monitor the progress of the treatment (Weiner & Greene, 2017).
DSM-5 Level 2 of assessing depression are used to measure the
12. progress that Eliza would be taking during treatment. Eliza
would require CCM-2 to measure her level of anxiety in the
first seven days of treatment (Weiner & Greene, 2017). Eliza
would be required to fill the CCM-2 questionnaire, which
contains eight items whereby she would be needed to rate the
severity of the depression in the last seven days. The physician
then interprets the data and determines the level of depression
of Eliza.
Apart from the assessment provided by APA, Eliza can
use online self-assessment tests to monitor her progress,
especially with the issue of anxiety. Anxiety was the major
problem that Eliza highlighted as a point of concern. She used
to avoid anxious situations to manage her condition (Bot et al.,
2017). Online assessments include questions similar to those of
other assessments tests. The patient is required to give genuine
information to be able to give genuine results. This process is
helpful, especially if the patient has to travel for a long distance
to see the physician.
The findings of the assessment should be conveyed to
Eliza in her native language. Diagnostic information should be
provided in a language that Eliza understands best. The
physician should maintain clear communication with Eliza
(Gilligan et al., 2018). Clear and improved communication
reduces the chances of adverse events by managing the anxiety
of the patient. Although there is no standard way of
communicating assessment results to Eliza or her family, the
physician should be keen to avoid chaos. Communication failure
can be disastrous (Gilligan et al., 2018). The physician should
be able to tell the patient the situation is under control.
The objective of the physician is to guide the patient
through the journey to a healthier state. The outcomes of the
treatment are dependent on not only the prescription of the
physician but also on Eliza’s willingness the get well and
thereby follow the instructions. If the patient misses
appointments or drops-out of the psychological therapies, it may
be difficult for the physician to deliver the agreed-upon
13. outcomes. However, patient follow-up helps keep the patient on
track. Strategies, measures, and outcomes are achievable when
the relationship between the Eliza and the clinician is
maintained.
Referral
Referrals are necessary when the clinician cannot offer
the services needed by Eliza. The clinician can request the help
of other professionals who can assist in the treatment process
(Russomagno & Waldrop, 2019). If the needs of the client are
outside the expertise of the clinician, a referral would be made.
Examples of referrals in mental illnesses include psychological
therapists, psychiatrists, family therapists, and mental health
nurse. The referrals would be necessary for Eliza to help her
understand her feelings. Therapists would allow her to cope
with the symptoms of depression.
The choice of referrals depends on the inherent
condition that requires the expertize of other professionals.
Eliza would require a psychological therapist who would enable
her to understand the feelings that are depressing her
(Russomagno & Waldrop, 2019). One can clearly see that Eliza
feels that she is alright and doesn’t need any mental care.
However, since the DSM-5 criteria showed that her experiences
meet the criteria, it is necessary for her to get treatment. For
this reason, a psychological therapist would help her understand
the feelings and situations that make her depressed.
Conclusion
Despite the overwhelming evidence on the prevalence of
depression around the world, there are just a few studies that
provide information on its treatment. Furthermore, treatment of
mild depression is not sufficiently researched, although some
studies propose various methods. However, there is one
common feature in all depressive disorders; that is, the patient
follows up. The therapeutic approach that was highlighted as a
possible treatment plan requires the clinician to constantly
follow-up the progress of Eliza. The study also pointed out the
14. importance of referrals in the treatment of depression.
References
Bot, M., Middeldorp, C. M., De Geus, E. J. C., Lau, H. M.,
Sinke, M., Van Nieuwenhuizen, B., ... & Penninx, B. W. J. H.
(2017). Validity of LIDAS (Lifetime Depression Assessment
Self-report): a self-report online assessment of lifetime major
depressive disorder. Psychological medicine, 47(2), 279-289.
DOI: https://doi.org/10.1017/S0033291716002312
Gilligan, T., Coyle, N., Frankel, R. M., Berry, D. L., Bohlke,
K., Epstein, R. M., ... & Nguyen, L. H. (2018). Patient-clinician
communication: American Society of Clinical Oncology
consensus guideline. Obstetrical & Gynecological
Survey, 73(2), 96-97. doi:
10.1097/01.ogx.0000530053.40106.9b
Gore, W. L., & Widiger, T. A. (2013). The DSM-5 dimensional
trait model and five-factor models of general
personality. Journal of abnormal psychology, 122(3), 816. Doi:
org/10.1037/a0032822
Russomagno, S., & Waldrop, J. (2019). Improving Postpartum
Depression Screening and Referral in Pediatric Primary
Care. Journal of Pediatric Health Care, 33(4), e19-e27.
doi.org/10.1016/j.pedhc.2019.02.011
Schwitzer, A. M., & Rubin, L. C. (2014). Diagnosis and
15. treatment planning skills: A popular culture approach (2nd ed.).
Los Angeles, CA: Sage Publications. ISBN-13: 9781483349763
U.S. Department of Health & Human Services, (2017). HIPAA
for Professionals. Retrieved from
https://www.hhs.gov/hipaa/for-professionals/index.html
Weiner, I. B., & Greene, R. L. (2017). Handbook of personality
assessment. New York, NY: John Wiley & Sons.
