For this assignment, you will select one of the case scenarios provided in the assignment`s Resources and analyze assessment tools that would support the diagnostic process for both the substance use and mental health issues presented. You will need to compare at least two assessments for each area of concern, including the client`s risk of harm to self or others, and point out the relative strengths and limitations of each. Consider scholarly literature and reviews for your selected assessment tool in the Mental Measurement Yearbook, if available, in order to analyze the level of appropriateness of the tool to assess clients from diverse backgrounds. Formulate a provisional diagnosis following DSM-5 criteria using the assessment template provided. Follow the template to address client strengths, challenges, and level of care (see page 75 of the text). This assignment sets the stage for the formulation of the treatment plan in u09a1.
Clinicians can reformulate the preceding placement criteria into a series of questions to help determine more restrictive versus less restrictive placement:1. Is the client’s condition associated with significant medical or psychiatric conditions or complications? If yes, lean toward restrictive. 2. What is the severity of actual or anticipated withdrawal from drug(s) being used? If severe, lean toward more restrictive. 3. Has the client failed multiple times at outpatient treatment? If yes, more restrictive is probably warranted. 4. What is the strength of the client’s support systems? If limited or no support system, restrictive may be best. 5. How severe is the client’s substance addiction, and is there a possibility of poly-substance addiction or abuse? The more severe, the greater the need for restrictive care.
As Fisher and Harrison (2009) noted, not all of these criteria or considerations may be used in determining client placement. That is, finances, insurance, time, and other client factors also shape what treatment setting a client enters. In my experience, clients who would benefit most from weekly outpatient counseling simply can’t afford this frequency of counseling. Believing that some counseling is better than none, I have had to compromise with clients and work within their financial abilities and other potential constraints.
The Treatment Plan
In many cases, clinicians must follow agency protocol for treatment planning, especially when it comes to completing paperwork. This usually involves a form or two that must be completed by the clinician and includes spaces to write a diagnosis, problem statement, goals, and objectives. Unfortunately, these forms often are inadequate for documenting a substance abuse (or dual diagnosis) counseling or treatment plan because they have limited space to write enough goals, objectives, and diagnoses. Many agencies are open to clinicians using their own forms or models of treatment planning as long as they comply with and are consistent with legal considerations. I recall in one particular agency that the director allowed me to add my own treatment-planning model to what the agency required. It was a bit more work, but in the end, I appreciated having additional latitude to account for the complexity of the client cases I was observing.
The importance of treatment planning is well documented (Miller, 2005; Seligman & Reichenberg, 2007). A comprehensive treatment plan serves as a compass, providing structure and direction to the counseling process and thus keeping clinician and client 7576from becoming overwhelmed (Miller, 2005; Seligman & Reichenberg, 2007). Treatment planning assures counseling with a higher likelihood of success, especially by helping clients and clinicians track progress; it is a way to determine if goals are being met, or if they need revision based on new client developments that inevitably arise during the counseling process. Miller (2005) stated, “The treatment plan serves as a rudder for the client work, assisting both the client and the counselor in keeping a balanced focus on the issues” (p. 87). Each plan must be specific and individualized to meet the client’s needs and goals (Perez, 2001).
Treatment planning also facilitates accountability between both clients and clinicians: Is the client working toward goals that she stated are important? Is the clinician using interventions as specified in the plan? Effective treatment planning is important for practical reasons as well, such as assisting in obtaining funding for projects, receiving third-party reimbursements, and providing defense in cases of legal malpractice suits.
Most treatment plans contain four essential components: the problem statement, the goals, the methods, and measurement (Miller, 2005). The four components should be written for each presenting problem. The problem statement is a sentence or two describing the major problem that brings the client to counseling. It should be written in clear and behavioral terms. The goals are what the client will accomplish to address the problem or, as Miller stated, the flip side of the problem. The methods are the interventions or what the clinician will do to intervene and help the client. The measurement answers the question, “How will we know when the client has accomplished his or her goal?”
Perkinson (2012) outlined a model for substance abuse treatment planning in which he lists the problem statement, followed by relevant goals, objectives, and interventions related to the problem statement. Clients may have one or more problem statements and, within each problem statement, they may have multiple goals, objectives, and interventions. In this context, goals refer to broad changes that the client will make to rectify the problem, and objectives are the actual behaviors he or she will engage in to accomplish the goals. Interventions are strategies and techniques to accomplish the objectives. Here is an example of a typical treatment plan based on the preceding description (Perkinson, 2012). Assume that the client has already been through detoxification and time in a residential facility.
Problem 1: The client is psychologically and physically dependent
Case Scenario 1
Tyrell is a 30-year-old African American homosexual male. He graduated from law school two years ago and feels fortunate to have a job as a law clerk in a prestigious law firm in New York. His job demands long hours, so it is not unusual for him to go several days with little sleep. His partner, James, is familiar with pushing the limits to get established in a career, so he suggested that they both take time to get away.
While on vacation, James was hoping to enjoy some downtime. In contrast, Tyrell seemed particularly keyed up the first few days. Rather than relaxing on the beach, Tyrell paced and seemed out of place among the happy vacationers. James made excuses for Tyrell’s agitated behavior, noting that it was difficult for many people to wind down after pushing so hard at work. The fourth night at dinner, Tyrell began berating a waiter who made a mistake in his order. Tyrell became uncharacteristically rude, suggesting that the waiter was not worth his time of day, and abruptly left the restaurant. James paid the bill and returned to the hotel only to find Tyrell out on the balcony of their room screaming, “Do you know who I am?!” at other guests. Becoming truly alarmed, James coaxed Tyrell back into the room and convinced him to take a walk to cool down. While Tyrell was gone, James wondered if his partner was “on something.” He went through Tyrell’s luggage and, upon finding some white powder, called Tyrell’s brother, Michael.
Michael was not shocked by James’s description of Tyrell’s explosive behavior. Michael recalled Tyrell being in trouble in college for similar behavior and that Tyrell had seen some kind of doctor as part of an agreement for him to remain in school. According to Michael, the incident blew over and the family attributed it to the stress of applying to law schools. When Michael went to visit Tyrell afterward, Tyrell seemed pretty down on himself and in a low mood in general.
Taking a risk to share an alternate explanation, James admitted that he had seen Tyrell at a club meeting some friends who were into meth, but he did not think much of it until now. The more Michael and James compared notes, the more concerned they became. James tried to convince himself that Tyrell had surely just got mixed up with the wrong people and got into “a little meth” in his attempt to keep up at work. But Michael was more skeptical and insisted that this sounded too similar to what his parents vaguely called “Tyrell’s episode.”
James and Michael’s debate was interrupted by another phone call. Tyrell was in a local hospital emergency room (ER) being treated for injuries after he took a swing at someone in a nightclub. He missed and hit a wall, injuring his hand. James debated whether he should tell the ER staff about his fears of Tyrell abusing meth or Michael’s description of the story from law school. He did not have to debate long, as the ER physician concluded that a full assessment was warranted based upon Tyrell’s insistence that he was the best lawyer in New York and the ER doctor better not “screw up” the best shot he would ever have to get out of that “crummy little hospital.” The ER physician referred Tyrell to the psychiatric crisis worker on call.
Case Scenario 2
Marifel is a 19-year-old woman of Filipino decent. She was born in the Philippines and moved to the United States with her parents when she was 2 years old. She has many relatives in the United States including aunts, uncles, and cousins, but her grandparents and some other extended family members remain in the Philippines. She visited them every couple years while growing up and often stayed for several weeks at a time. Marifel’s parents describe her as a happy child who was able to enjoy time with friends and family on two continents.
Unfortunately, this changed after Marifel was in a boating accident last summer.
Marifel was enjoying a high school graduation celebration with friends at a nearby lake when the accident occurred. The boat in which she was traveling struck a rock beneath the surface of the water at a high rate of speed, causing the boat to crash into a nearby pier. Marifel suffered severe injuries to her back and legs that required multiple surgeries, but her family felt lucky that she survived, as one of Marifel’s friends died of her injuries the night of the accident.
As Marifel struggled to recover from the accident, she came to rely upon opiate medications that were initially prescribed to help manage her pain. As weeks passed, her physical injuries healed, but she found that the numbing sensation that the opiates provided helped block the pain associated with the loss of her friend and memories of the accident. When her physician refused to refill her prescription, Marifel found contacts through a mutual friend who could supply the pills for a price. She found that the pills helped her sleep and gave her a warm feeling that helped her act like her old self. Whenever the pills ran out, she found that memories of the accident grew worse and popped into her head when she had quiet moments to herself. She has had some thoughts of hurting herself when she questions why her friend died while she survived, but with the relief of the pills, she has been able to push those thoughts away.
When she was physically well enough to travel, Marifel’s grandparents invited her to visit because they were anxious to see her. To everyone’s shock, she refused to travel to the Philippines. One of her cousins suggested that it might be because Marifel could not get enough pain pills to be away that long. This alarmed Marifel’s parents, who did not know how or where she was getting the pills. Searching Marifel’s room, they found plastic baggies tucked in odd places—some empty and some containing pills. At her parents’ insistence, Marifel agreed to meet with a counselor to help explore how she was really handling the accident.
Case Scenario 3
Miguel is a 60-year-old Mexican-American male. He is married and the father of three adult children who all live on their own. Miguel worked at a food processing plant for 20 years and advanced into a supervisory role until the company relocated a year ago, leaving him unemployed for more than six months. Miguel is proud that he supported his family and created a home where his children were able to grow up and enjoy a good education. Unfortunately, he saved little for his own retirement and has not told his wife that their meager savings will soon be depleted. Miguel recently found a position working in a recycling facility, but it pays only a fraction of what his previous position did. Miguel is anguished as to how he will support his wife and his mother who came from Mexico to live with them.
Miguel often pays bills after his wife and mother go to bed at night. He does not want them to worry, so he spends time carefully calculating the minimum payment for each creditor and noting on a calendar how late the payment can be mailed. His concentration has been rather poor so this takes him longer than usual. In spite of his efforts, some creditors have begun to call the house when the payments were late. His spirits have been steadily sinking as the reality of their finances broke his more characteristic optimism. When his family comments on how fatigued he looks, Miguel tells them that he is simply tired from the physical demands of this new job, but this is only partly true. Lately, he has begun to drink as he pays the bills at night to help ease his mind. He has trouble sleeping and reasons that maybe a drink or two may help him unwind. As he drinks, the reality of the bills do not go away, so he drinks a little more. This pattern has developed into a nearly nightly cycle of looking at the bills and drinking as he makes little progress toward a solution. His situation appears increasingly hopeless. His life insurance policy is one bill he makes certain to pay. It may be his final option.
In the past month, Miguel has found it difficult to get up in the morning for work due to his late nights with the bills. He has been late to work three times, and the last time, his supervisor smelled alcohol. He confronted Miguel. Miguel told him that he simply had grabbed the wrong shirt in the morning by accident. Perhaps he spilled a little something on the shirt the last time he wore it. Miguel’s supervisor shared how he had tried to cover his own drinking years ago and offered Miguel the chance to save his job if he agreed to follow the company’s referral process as part of the Employee Assistance Plan. Feeling cornered, Miguel agreed.