Case Study Treatment Plan: Treatment Goals


Case Study Treatment Plan: Treatment Goals
For this assignment, you will submit additional components of your treatment plan based on the case study you selected. You can view the case studies in the Case Study Treatment Plan multimedia piece, available in the Resources. Complete the following components of the Case Study Treatment Plan Template:

Treatment plan literature review.
Goals and interventions.
Communication with other professionals.
Legal, ethical, and other considerations.

The sections of your treatment plan for this assignment should be 46 pages in length and include a minimum of four references from the current professional literature in counseling. Be sure to cite your references in the current APA format.

Please continue to use the Case Study Treatment Plan Template to organize your work. Each section of the template includes a description of the type of information you need to include.

In the template for this assignment, also include the treatment plan components you wrote for the Unit 5 assignment so your instructor can refer to the previous information you provided about this client’s case when reviewing the components you have added for this assignment. When your template is complete, save it as a Word document with your name and submit it to the assignment area.

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 is 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 agencys intake caseworker. 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 Stellas 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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