Case Formulation and Treatment Plan

The study delineates the best practice for a patient diagnosed with substance abuse disorder. After doing an assessment and obtaining a diagnosis for the patient, a treatment plan was developed. The fifth edition of the DSM was used in order to arrive at a diagnosis (Diagnostic and Statistical Manual of Mental Disorders, 2020).  Case Formulation and Treatment Plan Essay Example

Karen, a young woman in her college years, is brought in by his father, who informs the doctor that his daughter has been drinking far too much recently. Since she was a young teen, Karen has had a long history of engaging in risky behaviors, including drinking excessively, using cannabis, and smoking cigarettes. Her use of these substances led to her getting arrested, being involved in a number of automobile accidents, experiencing a drop in her academic performance, and having a sporadic employment record. Karen’s failure to acknowledge the magnitude of her substance abuse and the impact it is having on her life, particularly in regard to her use of alcohol and marijuana, is particularly concerning. Karen has persisted in her usage of both of these things as a result of the aforementioned reasons since she is under the impression that her indulgences are having no effect on her at all.

At the age of fifteen, Karen took up the habit of smoking cigarettes, and it was at this time that she first introduced her partner to the habit. Since then, she has developed a more severe addiction to smoking, and now she uses a whole packet of cigarettes in a single day. She did eventually give up the habit of smoking at some point in the past. This was nearly 2 years ago, and she has since resumed smoking and has no intentions to quit at this time, despite the little break. As far as her drinking is concerned, she first started at the age of thirteen and then increased her consumption when she was seventeen. Since then, she has started drinking more, and at this point, she often engages in binge drinking. This is particularly true now that she is in college, where she frequently attends parties and gets involved in both social and college athletic activities.

At this point in time, Karen consumes on average at least four drinks containing alcohol throughout the course of a single week. She started using cannabis when she was eighteen years old, and her boyfriend was the one who first showed her how to smoke the herb. For the last year, she has made it a habit to partake in smoking cannabis up to three times on weekly basis, which sometimes involves sharing joints with her pals on Weekends. Additionally, Karen has given some thought to experimenting with many different types of drugs. For instance, she has come clean about her use of LSD, which is sometimes referred to as lysergic acid diethylamide, as well as heroin. On the other hand, she did not like the way that these stronger medicines rendered her feeling. She also acknowledged to considering to experiment with Xanax, which she said she did after receiving a recommendation to do so from another student. Karen does experience some moderate depressive symptoms on occasion, including feelings of sadness and stress, but she has not yet started taking the Xanax. The reliance on marijuana and alcohol that Karen has created has caused a rift in the relationship she has with her family.

TREATMENT PLAN

Assessment Date: 11/07/2022

Time of Assessment: 9 AM

Patient Name: Karen

Patient DOB: 4/04/2000

A treatment plan was created today, (11/07/2022).

This was an Initial Treatment Meeting.

Participants Developing the Plan: Two clinicians, a counselor, Karen’s father, and Karen

DIAGNOSIS:

1. Alcohol Use Disorder F10. 9

Justification of diagnosis: Karen has been taking alcohol in larger quantities over an extended period, exhibits a powerful desire to use alcohol, and has failed to meet the major role commitments at work, school, and home. She has also been involved in car accidents due to alcohol use.

2. Cannabis Use Disorder F12.20

Justification of diagnosis: Karen has been smoking marijuana for a long time, has failed efforts to cut marijuana use, and this has led to her failure to fulfill significant role commitments at work, school, and home.

3. Tobacco Use Disorder Z72.0

Justification of diagnosis: Karen has developed a more severe addiction to smoking cigarettes and currently uses a whole packet of cigarettes in a single day. She stopped smoking for a while in the past but resumed smoking and has no intentions to quit at this time.  Case Formulation and Treatment Plan Essay Example

MEDICATION:

Because this is Karen’s very first session, she is not presently on any kind of medicine. Both the expenses and the advantages of taking the drug have been explained to her. Does not plan to begin taking a medication right now. Since this is her first episode, she will be closely monitored so that it can be determined whether or not she will require medication in the future.

PROBLEM / SYMPTOM 1: Denial

Karen’s use of alcohol, marijuana and tobacco has led to notable effects and risks, which she fails to acknowledge. This is evidenced by:

• Her failure to seek medical help in a timely manner, to the expense of her health and life.
• Does not acknowledge the influence that drug use has had on her life pattern and does not recognize the personal significance of symptoms or risk.

LONG TERM GOAL:

It is necessary to make Karen understand the consequences and dangers associated with excessive substance use and take the necessary action (McLellan, 2017).

Target Date: (insert date) SHORT TERM GOALS

1. Verbalizing an understanding of the relationship between drug or alcohol usage and the current situations. This task will be accomplished by asking Karen to identify and describe many situations when alcohol, cigarettes, and marijuana have been involved, in addition to acknowledging what the outcomes were when using them (Imkome, 2018).

Frequency: once per week Duration: a day to two days Progress: Plans to start soon Target Date: (insert date) Completion Date:                         Status:             

Intervention:

Talk about how present living circumstances and the effects of drug usage. The realization by the patient of the connection between their drug use and their personal issues is the first step in the process of reducing the use of denial.

2. Participate in a rehabilitative program.  The patient will be assisted by the rehabilitative program in the process of substituting good behaviors that concentrate on recovery with ones that are harmful (Mahboub et al., 2021).

Frequency: once per week Duration: for 45 minutes Progress: Working on Target Date: (insert date) Completion Date:            Status:

Intervention:

Determine the reason for commencing the abstinence and engagement in therapeutic program. This provides clarity into the patient’s readiness to commitment to long-term behavioral shift, as well as whether or not the patient truly feels that she can change.

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PROBLEM / SYMPTOM 2: Ineffective Individual Coping

Karen demonstrates both a lack of personal resilience and inadequate coping abilities via her continued use of drugs. It is evidenced by:

1. Deficient adaptive behavior and problem-solving abilities.
2. Poor academic performance and employment difficulties (cannot keep a job)

LONG TERM GOAL:

Karen will explore alternative coping mechanisms.

Target Date: (insert date)

SHORT TERM GOALS:

1. Karen will identify inefficient coping strategies and the implications, including the use of drugs as a means of dealing with stress. This will enable her to be able to discover ways to adjust to her situations and cope with her problems without resorting to substances or alcohol (Shafiei et al., 2016).

Duration: one month Progress: Working on

Target Date: Completion Date:                               Status:             

Intervention:

The provider will instruct the patient on how to relax and will encourage her to do so via the use of relaxation techniques such as directed imagery and visualizations. This will assist the patient in relaxing, coming up with new strategies to cope with stress, and coming up with solutions to problems.

2. Karen will look into other methods of dealing with her drug binges with the help of her peers. Understanding, support, and the influence of peers are all powerful tools that may be used in self-help groups to facilitate the development of members and the promotion of abstinence (Stanojlović & Davidson, 2021).  Case Formulation and Treatment Plan Essay Example

Frequency: 3 times a week Duration: for 45 minutes Progress: Working on

Target Date: (insert date) Completion Date:             Status:             

PROBLEM/SYMPTOM: Altered Family Process

Karen admits that she does not have a healthy relationship with her family and feels that her parents do not love her. This is evidenced by:

• Refusal to get help
• Disturbed family dynamics
• Emotional isolation

Target date:

LONG TERM GOAL:

Karen will learn to relate with her family members in a healthy manner.

SHORT TERM GOALS:

1. Investigate how Karen’s family has managed their lives in light of the patient’s habit. The patient’s family also experiences the same feelings as the patient, making it necessary for the family to get assistance in developing new and efficient coping mechanisms (Tambling et al., 2021).

Frequency: Once a week Duration: 30 minutes Progress: Working on Target Date: (insert date) Completion Date:      Status:

2. Help the patient’s family understand that they are not responsible for the patient’s decision to abstain from drugs or use them in any way. The patient’s family members need to understand that despite their involvement in treatment, the patient’s habit may or may not change (Kourgiantakis et al., 2021)

Frequency: Once a week Duration: 30 minutes Progress: Working on Target Date: (insert date) Completion Date:      Status:

STATUS:

(Insert date): The undersigned clinician had a face-to-face meeting with the patient and her father on the above-mentioned day in order to collaborate with the patient in the creation of this Treatment Plan.

STRENGTHS:

Karen has identified the following strengths:

1. Supportive Her parents are the ones who noticed her substance use behavior and suggested treatment.
2. Karen is often a friendly and outgoing person who gets along well with others.

Preferences:

1. Karen prefers group

Signed By: (students name)

On: (insert date)

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.

Kourgiantakis, T., Ashcroft, R., Mohamud, F., Fearing, G., & Sanders, J. (2021). Family-focused practices in addictions: A scoping review. Journal of Social Work Practice in the Addictions, 21(1), 18-53. https://doi.org/10.1080/1533256x.2020.1870287

Imkome, E. U. (2018). Nursing Care for Persons with Drug Addiction. Drug Addiction, 49. https://www.intechopen.com/chapters/59036

Mahboub, N., Honein-AbouHaidar, G., Rizk, R., & De Vries, N. (2021). People who use drugs in rehabilitation, from chaos to discipline: Advantages and pitfalls: A qualitative study. PLOS ONE, 16(2), e0245346. https://doi.org/10.1371/journal.pone.0245346

McLellan, A. T. (2017). Substance misuse and substance use disorders: why do they matter in healthcare?. Transactions of the American Clinical and Climatological Association, 128, 112.

Shafiei, E., Hoseini, A. F., Parsaeian, F., Heidarinejad, A., & Azmal, M. (2016). Relapse coping strategies in young adults addicts: A quantitative study in Iran. Indian Journal of Psychological Medicine, 38(1), 46-49. https://doi.org/10.4103/0253-7176.175111

Stanojlović, M., & Davidson, L. (2021). Targeting the barriers in the substance use disorder continuum of care with peer recovery support. Substance Abuse: Research and Treatment, 15, 117822182097698. https://doi.org/10.1177/1178221820976988

Tambling, R. R., Russell, B., & D’Aniello, C. (2021). Where is the family in young adult substance use treatment? The case for systemic family therapy for young adults with substance use disorders. International Journal of Mental Health and Addiction, 20(3), 1659-1670. https://doi.org/10.1007/s11469-020-00471-1

NSG526 Case Formulation and Treatment Plan Assignment

Purpose: The purpose of this assignment is to complete a comprehensive treatment plan for a specific client (i.e., a client in your clinical practicum, a client in your place of employment, a family member or friend). Assessment, diagnosis, and treatment planning are components of the course and sections to be addressed in this assignment. You cannot use the same case used in another course.  Case Formulation and Treatment Plan Essay Example

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Assignment:

• The student will be required to provide a DSM-5 diagnosis, a treatment plan and a summary integrating evidence-based literature and justifying the treatment plan the student developed for the client. The student will also cross reference the diagnosis with the DSM 5 and note all patient symptoms matching criteria.
• This assignment should be 8 pages in length, excluding title page and reference pages following criteria below
• 10 total scholarly, peer-reviewed sources including DSM textbook (link below) and Incorporate at least 4 evidenced based research articles that support the diagnosis and treatment planning considerations.
• Must pass turn it in 24% or less
• This is a formal paper. Follow APA 7th edition format.

• Strongly conveys topic and delineates subtopics to be discussed in the body of text in the assignment.
• Content strongly related to topic; strong organization and integration of content within subtopics; and strong transitions linking subtopics and main topic.
• Support: Strong scholarly, peer reviewed support of topic; supporting materials are published within 5-7 years, as appropriate.
• Strong summarization with synthesis and insightful discussion of topic conclusions. No new information is introduced into the conclusion.
• Grammar, Spelling and Punctuation: No grammar, spelling, and punctuation errors.
• Writing Mechanics: Writing mechanics are consistent with formal scholarly work.

APA 7^th Edition:

• Peer reviewed scholarly resources are required. Scholarly sources include for example, professional, peer reviewed publications or reports from resources such as CDC, IOM, AACN, etc. These should be written by professionals and scholars in the field. Websites are only scholarly, if written by professionals and experts in the area. Wikipedia is not a scholarly source, for example. A web site such as Medscape, CDC, and TIGER Initiative are examples of scholarly sources.
• Peer-reviewed scholarly references that were written in the last 5-7 years.

.com web pages are not peer reviewed resources; webmd.com is not peer-reviewed

Please use USA sources.

• Avoid the overuse of direct quotations. Posts should include paraphrases of peer-reviewed works to display your understanding of the sources.
• Review capitalization and italics guidelines for article and journal titles in the reference list (p. 317 of APA Manual 7th ed.).

Periodical/journal names and volume numbers should be italicized (p. 317 of APA Manual 7th edition).

Journal/Magazine/News Articles:

The journal/magazine/newspaper titles are italicized and capitalized.

Article titles are not italicized.

Books:

Book titles are italicized.

Chapter titles are not italicized.

• Correct in text citations of works by multiple authors which has changed in APA 7th edition (p. 266 of APA Manual 7th ed.).
• Reference list citations of 2 works by the same author with the same date (p. 267 of APA Manual 7th ed.).
• No longer use “doi:” or “retrieved from”, instead just use a hyperlink or web address (p. 317 and p. 351 of APA Manual 7th ed.).
• Proper protocols for abbreviations (must define each abbreviation in text). Do not use abbreviations in reference list.  Case Formulation and Treatment Plan Essay Example

Textbooks:

American Psychiatric Association (APA). (2015). Diagnostic and statistical manual of mental disorders (5^th ed.). Author.

https://www.dropbox.com/s/4wgpksm0qdqmerg/Diagnostic%20and%20Statistical%20Manual%20of%20Mental%20Disorders%2C%20Text%20Revision%20Dsm-5-tr%20%28American%20Psychiatric%20Association%29%20.pdf?dl=0

Gabbard, G.O. (2014). Gabbard’s treatments of psychiatric disorders (5^th ed.). American Psychiatric Publishing

https://www.dropbox.com/s/r5wzarwdrw34wrn/Gabbard%E2%80%99s%20Treatments%20of%20Psychiatric%20Disorders%20by%20Glen%20O.%20Gabbard%205th.pdf?dl=0

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4^th ed.). Cambridge University Press.

https://www.dropbox.com/s/7b416fgkn9zaq9l/Stahls%20Essential%20Psychopharmacology%20Neuroscientific%20Basis%20and%20Practical%20Applications%20by%20Stahl%20S.M.%204th%20Edition.pdf?dl=0

Yalom, I. & Leszcz, M. (2020). Theory and practice of group psychotherapy (6^th ed.). Basic Books.

https://www.dropbox.com/s/mo9avyczisjg29c/The%20Theory%20and%20Practice%20of%20Group%20Psychotherapy%20%28Irvin%20D.%20Yalom%20%20Molyn%20Leszcz%29.pdf?dl=0

Case Formulation and Treatment Plan Essay Example