COUN6321: CASE STUDY TREATMENT PLAN: STELLA Instructions: Please type directly into this template as you develop your treatment plan. Your submitted assignments in Unit 5 and Unit 9 must be completed

COUN6321 Case Study Treatment Plan

Instructions: Please type directly into this template as you develop your treatment plan. Your submitted assignments in Unit 5 and Unit 9 must be completed within this template in order for you to receive credit for your paper.

Unit 5 Assignment: Complete the first six sections of the template, plus your reference list, for the Unit 5 assignment. After you have completed the final draft of these sections, save the template as a Word document with your name (for example, Smith Unit 5 assignment) and submit it to the courseroom assignment area by the deadline for the Unit 5 assignment.

Unit 9 Assignment: Complete the last five sections of the template, plus your reference list, for the Unit 9 assignment. Although your instructor will only review the last five sections to score your paper for Unit 9, please retain the information you have already written in the first sections within the template so your instructor can refer back to this when reading your Unit 9 assignment. When the full template is completed, save it as a Word document with your name (for example, Smith Unit 9 assignment) and submit it to the courseroom assignment area by the deadline for the Unit 9 assignment.

Case Study Treatment Plan

Your Name

COUN6321

Mental Health Counseling Clinical Internship 1

Case Study Treatment Plan

Unit 5 assignment sections: The Assessment Process (4–5 pages, plus references)

Section 1: Identifying Client Information

Describe this client in your own words. Do not copy and paste information directly from the case study here. Include demographic data and relevant context, such as living situation, employment, school, relevant history, current functioning, et cetera. Your description should be concise – it does not need to include every detail about the client -- and should be no longer than three paragraphs.

Section 2: Presenting Issues and Concerns

Describe the key concerns that have brought the client to counseling at this time. Include a brief description of any relevant history or other critical events that are related to the current issues.

Section 3: Previous Treatments

Summarize the client’s previous experience in therapy. Include hospitalizations as well as any community resources or other medical or mental health services the client has used. Include the degree to which previous treatments were successful; has the client had any experiences with previous treatments that may have an impact on the current counseling process?

Section 4: Strengths and Challenges

• Describe the client’s areas of strength and resilience.

• Describe the client’s limitations, challenges, or areas in which the client lacks knowledge, awareness, or specific skills.

• List the support systems the client currently has access to, such as family, friends, community groups, et cetera, and the extent to which the client is currently able to utilize these supports.

• Identify the key factors that may impact this client’s successful progress in counseling, how and why these factors may have an impact on treatment success, and how you will take these factors into account as you develop your treatment plan and interact with the client in sessions.

Section 5: Assessment Processes

Describe the process you will use to complete a comprehensive assessment of this client. If you intend to use specific instruments (such as self-report instruments, structured interviews, or psychological tests), state what they are and why you have selected them. Discuss any issues you will need to address regarding the relevance and biases of certain assessment tools with multicultural populations. Also discuss the methods you will use to arrive at an accurate DSM diagnosis for this client, including specific questions you will ask the client as well as others with whom you might consult about the client, such as previous counselors or doctors; family members; et cetera, with the client’s permission.

Section 6: Diagnosis

Present a full DSM-5 diagnosis for the client. Provide a description of your rationale for making this diagnosis. For example, what information was influential in arriving at this diagnosis? Discuss other possible diagnoses that you ruled out or will need to rule out once you have additional information.

References for Unit 5 Assignment

Support your decisions and ideas for the Unit 5 assignment with a minimum of two references to articles from current professional journals in the field of counseling. Use correct APA format.

Unit 9 assignment sections: Treatment Goals (4–6 pages, plus references)

Section 1: Treatment Plan Literature Review

Review the current research and best practices presented in the professional literature that relate to types of clients and presenting issues that are similar to the case you have selected. What does the literature have to say about the most effective types of counseling approaches used with clients who are similar in age, gender, stage of development, and share similar social-cultural backgrounds, history, current situations, symptoms, and/or presenting problems? Be sure to address the impact of diversity (age, gender, social-cultural background, et cetera) on the choice of counseling approaches and interventions, and include reference to clients who have addictions or co-occurring disorders. Summarize your review of the literature so it provides clear support for your choice of counseling approach, goals, and interventions that you will be presenting in the sections below. Keep direct quotes to a minimum; you should paraphrase the information you have reviewed in your own words. Remember to use correct APA format for all citations. This section should be a minimum of one page in length.

Section 2: Goals and Interventions

Based on the information you have reviewed about the client’s history and presenting issues, list four possible goals that you will work on with this client during the first three months of counseling. Your goals should include reference to the client’s addiction or co-occurring disorder, as well as to other issues the client has presented. Present these goals in concrete and specific terms. In other words, how will you and the client know when progress is being made toward a goal, or when a goal has been reached? What will be evident in the client’s thoughts, emotions, behaviors, interactions with others, et cetera?

For each goal, list two specific interventions that you will use during counseling sessions to assist the client in making progress towards that goal. Describe your rationale for selecting these interventions and what changes would you expect to see in the client during sessions if the interventions were effective. Be sure your interventions reflect the effective practices that you described in your treatment plan literature review; address how your approaches will also take the client’s sociocultural background into account and their appropriateness for addressing addiction and co-occurring disorders.

Section 3: Communication with Other Professionals

How will you develop and maintain a collaborative relationship with other professionals who are engaged in your client’s treatment? Describe with whom you will consult with as you develop your client’s treatment plan and begin to work with him or her in therapy (for this segment, assume that you have a written consent from the client to do so). This might include other medical or mental health professionals currently working with the client, as well as previous therapists; it could also include experts in the field with whom you may want to consult about the client’s presenting issues. You may also decide to consult with members of the client’s family. What is your rationale for consulting with these persons and how might this information inform your work with the client?

Section 4: Medications

Discuss in the section any medications your client is currently taking or has taken in the past. What impact might these medications have on the client, such as side effects, improvement in symptoms, interactions with other substances, et cetera? What additional information will you need to obtain about the client’s use of medication and with whom will you consult about this? What information do you want to provide to the client about these medications and how might you need to continue addressing the issue of medication in your work with this client over time?

Section 5: Legal, Ethical, and Other Considerations

Describe any potential legal or ethical issues that may arise as you work with this client and how you will address them. Refer to the specific state laws or ACA ethical standards in your discussion. Also list any other potential red flag issues that you have identified and the ways in which you may need to address these issues with the client.

References for Unit 9 Assignment

Support your decisions and ideas for the Unit 9 assignment with a minimum of four references from current professional journals in the field of counseling. Use correct APA format.

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 difficult 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 days before he leaves on another trip. Stella reports that she feels “lonely and blue” when her husband is away. She finds it difficult 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 first full-time job was back at the grocery store, where she worked in the office 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 off 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 effectively. 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 find 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 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 briefly by phone and plan to meet with her next week.

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