Treatment Plan and Progress Monitoring
The biopsychosocial evaluation is a test done before starting treatment or counseling. Clinical aid is required after analyzing Eliza’s case from many angles and levels from a clinical standpoint. It is simpler to decide on the diagnosis, course of treatment, theoretical approach, and progress monitoring method after analyzing Eliza’s case and the presenting problems. The biopsychosocial assessment is designed to briefly explain the data and allow the therapist to ascertain whether any further issues, such as homicidal and suicidal ideas, have been raised. The evaluation provided symptomology that can be objectively analyzed using the DSM-5. Eliza has been identified as having adjustment difficulties and a depressed mood. Anxiety is the adjustment issue in this situation. Since anxiety is the most prevalent diagnosis, more testing is necessary to determine the best course of treatment.
The initial course of treatment and existing objectives are intended to reduce alcohol intake, and anxiety levels, improve self-esteem, control stress factors, and eliminate suicidal ideas. Working on maintaining these goals and putting sustainable solutions into place would be the focus of the therapist’s and Eliza’s therapeutic relationship. Eliza’s responsibilities outside of therapy would include working on identifying additional potential dangers and triggers in addition to actively participating in programs. This responsibility will consist of looking into campus events that could strengthen her social relationships and give her access to a new natural support network.
Eliza will also be encouraged to take the necessary downtime to unwind and refocus, and she will kick her alcohol addiction, leave her dorm, and improve her perspective. It should be mentioned that the mending process takes time. Eliza will also be urged to express any troubling ideas or triggers causing her to consider suicide and the topics covered in treatment.
Treatment Plan Development
According to the case study’s information, Eliza has an adjustment disorder with a depressed mood (O’Donnell et al., 2019). The DSM-5 lists several different kinds of adjustment disorders, which are stress-related ailments that manifest when a person cannot manage or adapt to a specific stressor. Eliza’s declining grades in her core engineering classes, which have caused her severe distress and functional difficulties, are the explicit stressor in her situation. Her signs of depression, suicidal thoughts, alcohol misuse, and self-harm support the diagnosis of adjustment disorder with depressed mood; more specifically, she suffers from an anxiety disorder. The ICD-11 classification system recognizes adjustment disorders as stress-related ailment that can be categorized as F43.2 Evans et al., 20210. Eliza is also struggling with alcoholism, indicated by the number F10.10.
| Client: Eliza | Date: | Age: | DOB |
| ICD-9 (ICD-10) Code: | SDM-5 Diagnosis ( Include specifies and modifiers): | ||
| F43.23 F10.10 | Adjustment disorder with anxiety and depression (Ma, 2022) Alcohol Use Disorder | ||
| Description of a Problem | Eliza reported that she was feeling stressed out and overworked as a result of her assignments. She uses unhealthy (self-harming) behaviors that negatively affect her lifestyle as a coping mechanism. With her excessive drinking, cuts on both wrists, and usage of over-the-counter drugs, Eliza was showing signs of having recently tried suicide. | ||
| Goal | This professional examination seeks to lower stress and anxiety levels from a 9 (suicidal ideation) to a 5 (depressed mood affects only half of the day/every day). | ||
| Objective | Intervention | Target | |
| 1. Mood stabilization to maintain calm and avoid feeling overwhelmed. 2. Creating coping strategies and abilities to enhance functioning for four weeks. 3. Recognize the verbalization of anxious and depressive feelings for two weeks 4. Complete two weeks of anxiety and depression psychological testing. | 1. Writing down ideas and problems as they occur to her and elaborating on them is known as journaling. 2. Techniques for relaxation: Since Eliza seems overburdened, we can lead her in relaxing activities like yoga and meditation. 3. Group psychotherapy: Use an encouraging group to talk about their challenges and strategies that have helped them. 4. Scheduling a day: Plan your priorities in a planner, and include how much time you’ll need for schoolwork. 5. CBT: Reduce self-harming ideas and strengthen problem-solving skills. Cognitive exposure and boosting of positive worry-related attitudes in group psychotherapy Examining potential hospitalization or dangerous behavior – Conduct evaluations for self-harm and suicidal thoughts. | 6 months 2 weeks 2 weeks |
| Description of the Problem: Eliza continuously drinks alcohol, binge drinks every night before bed, and goes out to a party every weekend to relieve her stress from school. Eliza attempted suicide with the help of over-the-counter medications and alcohol after receiving poor grades in her preliminary engineering subject. |
| Goal: Replace alcohol abuse with new coping ways |
| Objective | Intervention | Target |
| 1. Determine the circumstances that would cause alcohol usage. 2. Continuously practice self-care, a better sense of worth, and motivation | CBT would help in practice thought-stopping for demoralizationSkills training would help in coping skills and apply them three times a day | 2 weeks |
| 3. Make a strategy to avoid relapses. | Social learning processing Recognize cravings and triggers Create coping mechanisms for preserving sober. | 6 months |
Part 2: Problem Identification and Diagnostic Decision-making
The DSM-5 level 01 Cross-Cutting Measure is a 23-item evaluation that evaluates a client’s symptoms of addiction concerning their diagnosis (Lace & Merz, 2020). The psychological issues will aid a counselor in comprehending the client’s underlying feelings, which may be closely related to adjustment disorder with anxiety and depression. The examination thoroughly describes the client’s symptoms and more precise identification of comorbidity diagnosis. Given that she may have two conditions, employing the Level 01 Cross-Cutting Measure will aid in identifying any other illnesses for a precise diagnosis.
Eliza has been identified as having adjustment disorder, anxiety, depression, and alcohol addiction as co-occurring disorders. Eliza has gone through a rollercoaster of emotions due to the pressure of studying and keeping a high GPA. The more specific symptoms Eliza is experiencing that cause her to act and react the way she does will be found using the cross-cutting measure. Eliza’s adjustment disorder diagnosis, anxiety, and sadness are chronic, although co-occurring alcohol addiction is minor. I need to comprehend the underlying persistent symptoms to ensure that the behaviors and symptoms are consistent with the diagnosis. Eliza exhibits a wide range of emotions and actions. Thus the assessments will evaluate each component of anxiety, fear, and depression to differentiate between illnesses of anxiety and depression.
Eliza was initially screened and found to be using alcohol as a stress reliever, which led to her being diagnosed with AD, which includes depression and anxiety as well as irrational thoughts, intense tension, and suicidal ideations. Although stress was the primary trigger for alcohol use, the intake nonetheless fulfilled the DSM-5 criteria for substance abuse disorder and had the potential to worsen over time. However, recent times have seen an increase in depressive-like actions and thoughts. Excessive worry, jitteriness, a sense of hopelessness, a decline in self-esteem, a lack of drive, and behaviors associated with suicidal thoughts are symptoms that meet the criteria for AD with anxiety and depression in the DSM-5. Similar to Eliza’s situation, it is typical for diseases like alcoholism and suicidality to co-occur.
Part 3: Theoretical Approach
Utilizing evidence-based techniques that have been tested for similar diagnoses and presenting issues is crucial for increasing the efficacy of an intervention. Since CBT concentrates on the typical side effects of AD with anxiety and depression, it is a more effective treatment than behavior therapy. Psychotherapy with Eliza may help with feelings of poor confidence, social anxiety, demoralization, and sadness when difficult situations arise. CBT strategies must incorporate more outstanding anxiety management when discussing the client’s presenting issues to lessen numerous worrying symptoms and hopelessness (Schwartz et al., 2019). When CBT is used to manage anxiety, one of its most vital coping skills is incorporating coping techniques into daily life.
Eliza also gave a ton of false impressions, inaccurate information, and suicidal tendencies. Safety for Eliza is paramount, and suicide prevention techniques will be covered in class. The four steps of the CBT process are: recognizing the unfavorable perceptions and predictions; identifying the evidence of the truth or falsity of the thoughts; altering the cognitions to a more accurate belief; and finally developing strategies to help the client bring their beliefs to reality when anxiety and stress occur (Killij et al., 2022). The client responded poorly after receiving an average grade in her preliminary engineering subject, binge drinking, and abusing over-the-counter medications to avoid waking up. To ensure the client and the counselor feel secure, safety measures at this point include evaluating psychological exams and creating a safety plan rather than a contract.
The neurobiology and compulsive, habitual behaviors that lead to dependency are not helped by just one cognitive behavioral therapy (CBT) intervention for alcohol addiction and co-occurring disorders (Salomonsson et al., 2020). Successful approaches and ethical/legal concerns are required for substance abuse and suicide ideation prevention strategies. It is crucial to document and record acts made, interventions given, and moral/legal deeds carried out in this instance via the prism of counseling CBT. Different tactics will be employed in this case to accomplish the objectives established, but it is also possible to use outside resources and additional assistance to motivate positive activities. Risk management, ethical, and legal considerations will be considered when speaking and interacting with any care providers.
Part 4: Progress Monitoring
Compared to Level 01 CCM, the Level 02 Cross-Cutting Measure (CCM-2) will include more in-depth inquiries—additional assessments for Level 02 CCM can be chosen based on the data provided by Level 01 CCM. Several different assessments must be used in therapy. The more severe psychiatric domain symptoms that have been present for at least seven days will be addressed by the level 02 CCM. To track whether the severity has decreased or increased as the course of therapy progresses, it is crucial to keep using the level 02 assessments.
The client’s safety, as previously indicated, is of the utmost importance because she has been exhibiting highly negative emotions, behaviors, and ideas. It can be typical for AD patients to experience anxiety and depression, so it’s essential to monitor these feelings. Reducing tension and anxiety is one of the goals of the treatment strategy. The Depression Anxiety Stress Scale (DASS-42) and The Beck Scale for Suicidal Ideations are two tests that examine symptoms connected to the objective (Abdullah et al., 2023). The DASS-42 will concentrate on the two domains present, while the Beck Scale will monitor suicidal ideations. These evaluations will assist the counsellor in continuing to focus on the actions and ways of thinking that are connected to the symptoms. Repeating these assessments will enable the therapist to stay informed about Eliza’s experiences and session presentations.
With the measurements taken throughout psychotherapy, the client and the therapist can observe improvements in the client’s presenting symptoms. Given the severity of her symptoms, it would also be beneficial to inform the client’s family of the results of the evaluations. With permission, the family may see the evaluation results and submit their evaluations of Eliza to monitor her progress. In addition to the counselor’s and Eliza’s viewpoints, this could elicit different viewpoints. The treatment plan’s tactics and treatments were developed to help, not make the symptoms worse. The assessments’ findings help identify how well treatments and interventions work and allow for necessary revisions. Since the client’s wants and goals are the focus of all the effort, if the methods don’t work, they will be changed in favor of more successful results and actions. The progress will be tracked to determine Eliza’s next course of treatment.
References
Abdullah, M., Khalily, M. T., Ruocco, A. C., & Hallahan, B. (2023). Impulsivity, suicidal thoughts, psychological distress, and religiosity in adolescents and young adults. Frontiers in Psychiatry, 14. https://doi.org/10.3389%2Ffpsyt.2023.1137651
Evans, S. C., Roberts, M. C., Guler, J., Keeley, J. W., & Reed, G. M. (2021). Taxonomy and utility in the diagnostic classification of mental disorders. Journal of clinical psychology, 77(9), 1921-1936. https://doi.org/10.1002/jclp.23125
Kellij, S., Lodder, G. M., van den Bedem, N., Güroğlu, B., & Veenstra, R. (2022). The social cognitions of victims of bullying: A systematic review. Adolescent research review, 7(3), 287-334. https://link.springer.com/article/10.1007/s40894-022-00183-8
Lace, J. W., & Merz, Z. C. (2020). DSM-5 Level 1 cross-cutting measure in an online sample: evaluating its latent dimensionality and utility detecting nonspecific psychological distress. Psychiatry Research, 294, 113529. https://doi.org/10.1016/j.psychres.2020.113529
Ma, F. (2022). Diagnostic and statistical manual of mental disorders-5 (DSM-5). In Encyclopedia of Gerontology and Population Aging (pp. 1414-1425). Cham: Springer International Publishing. DOI: 10.1007/978-3-030-22009-9_419
O’Donnell, M. L., Agathos, J. A., Metcalf, O., Gibson, K., & Lau, W. (2019). Adjustment disorder: Current developments and future directions. International journal of environmental research and public health, 16(14), 2537. https://doi.org/10.3390/ijerph16142537
Salomonsson, S., Santoft, F., Lindsäter, E., Ejeby, K., Ingvar, M., Ljótsson, B., … & Hedman‐Lagerlöf, E. (2020). Effects of cognitive behavioural therapy and return‐to‐work intervention for patients on sick leave due to stress‐related disorders: Results from a randomized trial. Scandinavian journal of psychology, 61(2), 281-289. https://doi.org/10.1111/sjop.12590
Schwartz, C., Barican, J. L., Yung, D., Zheng, Y., & Waddell, C. (2019). Six decades of preventing and treating childhood anxiety disorders: a systematic review and meta-analysis to inform policy and practice. BMJ Ment Health, 22(3), 103-110. http://dx.doi.org/10.1136/ebmental-2019-300096
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