Continue in your role as an intern with the substance abuse facility.
Assume the management team at your facility has asked for your help in preparing a treatment plan for the client in the case study.
Prepare a 1,050- to 1,400-word proposed treatment plan summary, including your ideas for a treatment plan. Refer to the Elements of a Treatment Plan document as you prepare your summary.
Include the following:
- Summary of diagnostic issues
- Problem list
- SMART goals
- Possible interventions
Explain how, as a future case manager, you would track and evaluate progress against the plan.
Include at least 2 references.
Format your treatment plan report according to APA guidelines.Treatment plans should always be client driven and treatment team supported. Further they should help the client consider how alcohol or substance abuse is impacting all aspects of your clients life, including the clients mental, physical, social, financial and legal histories. This document should be fluid and must be updated as the clients needs change over time or as goals are met. All treatment plans contain the following elements in a treatment plan.
A Diagnostic Summary
The clinical provider will meet with the client and discuss their alcohol and/or substance use patterns, medical history, mental health disorders and legal issues. Based on these assessments, the provider will summarize the main problems that brought the client in for treatment, and recommendations like medication and behavioral therapy based on acceptable treatment practices and possible facility limitations.
A Problem List
The problem list addresses specific issues that the client wants to target during treatment and a summary of the signs and symptoms that highlight the individual problem(s).
Problem (1): Angel has the inability to reduce or stop alcohol and substance intake.
This is evidenced by: Angel having both a DUI and a domestic violence arrest in the past year.
This is evidenced by: Angels Extensive alcohol use (on average six vodka shooters and a six- pack of beer daily) multiple times per week. This is in conjunction with marijuana usage in the morning and right before he retires for the night.
After the client and provider create the problem list, the goal list encourages forward thinking about possible solutions. Goals are brief statements about what the client wants to change.
- Based on the clients problem list (these should directly relate to the alcohol or substance abuse or fall out from the use)
- Comprehensive (focused on how to replace a harmful behavior with a healthy one)
Learn new anger management skills.
Learn how to have difficult discussions with my wife.
Goals are things you want to change, while objectives are individual steps you will take to achieve each of those goals. Objectives should be SMART:
- Measurable (actions that can be seen)
- Attainable (reasonable to achieve within the treatment period)
- Relevant (related to the issues on your problem list)
- Time-limited (have a target date for completion before discharge)
Gain new insight in how to live sober by going to group counseling
Find a sponsor for myself at the Dragons Den 12-step meeting
Complete steps 1-4 of Alcoholics Anonymous with my sponsor
These are the methods your treatment team will use to help you achieve each of your objectives.
- Problem: Angel has the inability to reduce or stop alcohol and substance intake
- Goal: Learn new coping skills
- Objective: Find a sponsor for myself at the Dragons Den 12-step meeting
- Intervention: Treatment team will provide a pass for the client to attend the Dragons Den 12-step meeting, monitor weekly 12-step attendance, and help resolve barriers to attendance, such as providing light rail passes.
Tracking and Evaluating Progress
Your treatment team will keep client treatment notes in your jacket to track your progress and evaluate whether a treatment plan is working. The notes have details about the clients response to treatment, changes in the clients condition, and changes or updates to the plan. Charts may also include worksheets that include the clients thoughts, feelings, and behaviors or journal entries.
Relapse prevention planning
During treatment planning, your clinician should discuss discharge planning and the creation of a relapse prevention plan. After the client has successfully completed the initial treatment program, the clients relapse prevention plan may include:
- Maintaining attendance at 12-step meetings
- Starting work with a peer recovery coach
- Beginning Medication Assisted Therapy (MAT) for alcohol use
- Contact my sponsor if I am triggered and have using thoughtsngel Case Study(Anxiety, PTSD, Substance Use Disorder)Case Study Details
Angel is a 44-year-old separated man who says that his substance dependence and his anxiety disorder both emerged in his early 20s after joining the army. He says that he started to drink to feel better at the NCO club on base when his episodes of anxiety made it hard for him to interact with his peers. He states that his anxiety became extreme after his first deployment to Iraq. He worked as a military police officer and was often exposed to hostile fire as his group supported operations. He also states that alcohol and now cocaine were a part of his dishonorable discharge. His wife called police after an argument regarding his drinking. He shoved her and police arrested him and charged him with domestic violence (DV). He was required to attend DV classes as well as substance abuse treatment as part of the plea. He further has community service hours (48) and 2 years of probation. You are conducting the intake assessment into your treatment agency. Angel notes that coming off the cocaine and binge drinking contribute to low mood and increased anxiety, but he has not responded well to referrals to adjunct support services, and past inpatient stays have led to only temporary abstinence. He does not have VA connected benefits and his job as a cook offers no insurance coverage. Yet, Angel is now trying to forge a closer relationship to his adult children, and he says he is especially motivated to get a better handle on both his PTSD and his substance use because he will be a grandfather in January. Angel states he and his wife are currently separated but talk on a daily basis. Symptoms
· Alcohol Use · Depression · Anxiety · PTSD · Substance Abuse Diagnoses and Related Treatments
The following treatments have empirical support for individuals with?PTSD: · Cognitive Processing Therapy (CPT) · Trauma-focused Cognitive Behavioral Therapy (cf-CBT) · Eye Movement Desensitization and Reprocessing (EMDR)Mixed Substance Abuse/Dependence
The following treatments have empirical support for individuals with?Mixed Substance Abuse/Dependence: · Motivational Interviewing plus CBT for Mixed Substance Abuse/Dependence · Seeking Safety for Mixed Substance Abuse/Dependence · Motivational Enhancement Therapy (MET) for Substance Abuse Treatment Generalized Anxiety Disorder
The following treatments have empirical support for individuals with Mixed Substance Abuse/Dependence: · CBT for Generalized Anxiety Disorder · Psychoeducation · Mindfulness Adjunct support services · AA, NA or other 12-Step program · SMART recovery · Peer Recovery Coaching · Mindfulness Recovery