Diagnosis and Treatment Planning
The clients name for this case study is John and he is a 21-year-old Caucasian male who lives in an upper-class neighborhood. John comes into counseling experiencing auditory hallucinations and delusions for the last 6 months. John also reports feeling paranoid on a regular basis saying that the devil is out to get him. John also reports social isolation and diminished family relationships.
The learner chose to utilize the Symptom Checklist (SCL-90-R) as an assessment to help her reach her diagnosis. Pauker (n.d) states that the SCL-90-R is a self-report instrument that can help differentiate between different psychological symptoms (Pauker, n.d). The learner would use this assessment by having John fill it out and indicate what symptoms might be problematic for him. However, an issue with self-report instruments is that clients can lie in an overly negative or positive manner (unless they have developed insight into what is going on with them). However, the learner likes this assessment because it gives John a voice to disclose what symptoms he feels that he is experiencing and it gives her a chance to see his level of insight.
The learner plans to use a published assessment called The Scale for the Assessment of Positive Symptoms (SAPS). This assessment is useful in measuring the severity of certain symptoms of schizophrenia such as delusions and hallucinations. King (2014) states that SAPS is good at helping differentiate between clients with positive and negative symptoms (King, 2014) When she read about SAPS, she learned that reliability and validity for this assessment is decent. The learner would utilize the SAPS assessment in conjunction with the information collected from family members.
It is important to make sure the instrument that is chosen has good reliability and validity because otherwise the results gained from the SCL would be useless. Pauker (n.d) says the SCL had good test-retest reliability which is important. The article does not mention too much about validity, but the learner would postulate that this assessment would not be used if the validity was awful. The learner needs to be cognizant about what level reading level John is at before issuing this assessment to make sure it is appropriate for his reading level. Pauker (n.d) says that the SCL-90 requires a minimum of an 8th grade reading level (Pauker, n.d). This is why it would be important to inquire with John about his educational level and background so that the learner could pick out assessments that would be appropriate and respectful of him as well. Both SAPS and the SCL-90-R can provide useful information for the learner to work with in John’s case. She must also choose assessments that she is qualified to administer as well as culturally appropriate.
During the assessment process, the learner would ask John to describe how his current symptoms that brought him into counseling affected his social relationships. This is an important part of the assessment process and can encourage insight. Riecher-Rossler, Gschwandtner, Borgwardt, Aston, Pfluger, & Rossler (2006) states changes in social relationships can indicate early signs of schizophrenia (Riecher-Rossler et al., 2006). It will be important to maintain the therapeutic alliance throughout the assessment process so that John is more open to understanding and exploring what is going on with him.
After going through the assessment process with John the learner would provide a provisional diagnosis of schizophrenia with a diagnostic code of 295.90. John struggles with hallucinations and delusions to where his quality of life is deteriorating rapidly. His relationships with his father and brother are strained due to the negative thoughts that he experiences about them and the paranoia that he thinks they are out to get him. CBT might be useful to help John work through those thoughts once he has gotten to a stable point in therapy. John experiences grandiose delusions where he thinks that he is better than what he is, and fails to acknowledge that there is an issue. The therapeutic alliance will be important to make progress with John. The APA (2013) states that for a schizophrenia diagnosis to be made John must be experiencing either catatonic symptoms, delusions, hallucinations, or disorganized speech patterns (American Psychiatric Association, 2013).
The learner also selected this diagnosis because John’s quality of life has declined since he has experienced symptoms and relationships have rapidly deteriorated. His father reported that he has gone in psychotic episodes that have been difficult for the family to cope with. John has been hospitalized in the past to manage his psychotic episodes. Thomas, Alptekin, Gheorghe, Mauri, Olivares, & Riedel (2009) states that the first 4 days is crucial to help manage and alleviate the symptoms from the psychotic episode, and benzodiazepines are commonly prescribed to address anxiety (Thomas et al., 2009). On the other hand, benzodiazepines must be used with caution because of the risk of addiction associated with them. During the diagnosis process, the learner would need to account for and ask about what medications John is currently and has been prescribed in the past and whether the medications turned out to be helpful or not.
Diagnosing using the DSM has its advantages and its disadvantages. Diagnosing can help give the clinician and the client a picture of what is going on with them. Sometimes clients might present in counseling scared because they do not understand what is going on with them, and just seek answers even if it is answers they may not particularly like. Diagnosing gives a chance to strengthen the therapeutic alliance and give the clinician a chance to process the diagnosis with the client. On the other hand, certain mental health disorders (such as schizophrenia or bipolar) carry a heavy stigma that may lead to the client experiencing negative emotions. Ben-Zeev, Young, & Corrigan (2010) declares that we must understand what it means for the client to experience being labeled to understand what it is like to live with a stigma associated with mental illness (Ben-Zeev, M, & P, 2010). It is important to emphasize that the client’s identity is separate from their diagnosis, and that it does not define who they are. This might be something they immediately struggle with after diagnosis, and may need a couple of sessions to help process.
Gathering of Information from Treatment Plan
The learner would want to gather more information about how John’s social relationships was impacted by his symptoms, and information about medications he might have been prescribed during previous hospitalizations. It is also important to explore if he has had any physical ailments (ex cancer or AIDS) and the status of any of those diagnoses as well. The reason is because he could experience depression symptoms or experience a stigma from those diagnoses and it would be important to work through those counseling as well.
She would incorporate current research and diagnostic resources by staying up to date on diagnosis and research by taking continuing education (CE) units or participating in conferences whenever possible. The learner just found an article describing cognitive remediation as a new intervention to help treat schizophrenia. Eack (2012) states that cognitive remediation focuses on neurocognition and some programs focus specifically on social cognition There are some programs that might focus on a combination of both aspects, but all three types present a variety of options.
Ultimately, the learner would utilize cognitive behavioral therapy (CBT) when working with John. CBT is an effective approach that focuses on changing faulty cognitions and dysfunctional thinking. She posits that CBT might be useful to help tackle certain cognitions such as John feeling like his brother is out to get him, and can help work on the paranoid thoughts that he experiences. Dopke & Batscha (2014) states that CBT is now proven to be an effective treatment for psychosis symptoms (Dopke & Batscha, 2014). CBT is great in helping an individual’s self-esteem because it focuses on negating the negative cognitions that the client is experiencing.
Elements of the Treatment Plan
Treatment plans is something that outlines a progress or plan of how therapy will progress (N.A, N.D). The purpose of treatment plans is to give an outline or a plan of how therapy likely should progress. It is difficult to predict how therapy will go precisely, but it gives a road map that the clinician and the client can work with.
Focus of Therapy
The focus of therapy should be to help John learn to cope with the diagnosis and develop his own separate identity separate from the schizophrenia diagnosis. Wykes & Callard (2010) says that diagnosing is important to help locate possible treatments (Wykes & Callard, 2010). Another focus for therapy will be to help John learn about what he wants for his life and to help provide him resources so he can accomplish those goals.
Goals for the Client
Lessen the number of psychotic episodes that John experiences in each month from 3 to 1 and to ultimately cease the psychotic episodes. Thomas (2009) states that an important goal would be to control psychotic symptoms and prevent any type of harm that could be present (Thomas et al., 2009). Another treatment goal would be to lessen the amount of paranoid thoughts about his brother from them happening every day to negating them completely. Such thinking has contributed to his psychotic symptoms and needs to be addressed.
Goals to Address the Relational Problems
Help John develop a more functional relationship with his father and his brother. The goal would be to encourage positive communication from the starting point of 0 to daily. Eack (2012) says that people that are diagnosed with schizophrenia struggles with impairments in social cognitions (Eack, 2012). Considering a cognitive remediation program that specifically focused on social cognition might be helpful for John since he experiences severe deficits in this area.
Specific Intervention for Individual Goals
The learner would utilize the ABC model as an intervention to help John develop insight into his symptoms. A stands for activating event, and the learner would want to help him recognize and work through his triggers. B stands for belief and would want John to write down in a journal the thought that comes to mind when he is triggered. Another intervention would be to encourage John to adhere to medication (assuming there are no side effects and the medication is working. Thomas (2009) acknowledges that antipsychotic medication can be useful in lessening symptoms (Thomas et al., 2009).
Specific Interventions for Relational Problems
The learner would utilize role-play with John to help him practice how to interact with his relatives in a more positive manner. Another intervention she would use is having John record a journal with the paranoid and irrational thoughts he experiences and how often he experiences them. Journaling can be a helpful outlet for him and help him learn more about himself and who he is, which is an important part of the therapy process. Dopke & Batscha (2014) suggests that determination and developing their own identity is an important part of the recovery process (Dopke & Batscha, 2014).
Environments and Social Systems
When working with John, the learner would need to be cognizant of his environment. His socioeconomic status, the city he lives in and resources that he may or may not have adequate access to will play a role in his treatment. John is in a low economic bracket, but his parents does live in a better economic bracket and might be able to contribute to some treatment sources for him. On the other hand, assuming they do not want to contribute then the learner would need to find resources that would fit his situation. Van Os, Kenis, & Rutten (2010) says that different factors such as childhood trauma, marijuana use, a growing up in a poverty-stricken environment might be risk factors for schizophrenia (Van Os, Kenis, & Rutten, 2010). It would be important to explore what resources John might have access to on his own such as insurance that might be able to help for his care. Another thing to recognize would be the rules of the learner’s workplace in regards to giving out treatment to those who cannot afford to pay and what resources would be available to give out in those circumstances.
This course project gave the learner the opportunity to invent a case study and practice diagnosing in a hypothetical situation. She really appreciated this opportunity because it made her think how she would handle diagnosing and creating treatment plans once she is a licensed counselor. She had the opportunity to formulate a diagnosis and provide a reasoning behind it as well as create a treatment plan with treatment goals. This was helpful because she struggled with making detailed goals at Track 1 Residency, and this is an area she would continue to love more practice in.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed ed.). : .
Ben-Zeev, D., M, Y., & P, C. (2010). DSM-V and the stigma of mental illness. Journal of Mental Health. Retrieved from Capella
King, S. (2014). Review of the Scale for the Assessment of Positive Symptoms. Mental Measurement Yearbook. Retrieved from Capella
N.A (N.D). Definition of Treatment Plan. Free Dictionary. Retrieved from Freedictionary.com
Pauker, J. (n.d). Review of SCL-90-R. Mental Measurements Yearbook. Retrieved from Capella
Riecher-Rossler, A., Gschuwandtner, U., Borgwardt, S., Aston, J., Pluger, M., & Rossler, W. (2006). Early detection and treatment of schizophrenia: How early? Retrieved from Capella
Thomas, P., Apterin, K., Gheorghe, M., Mauri, M., Olivares, J., & Riedel, M. (2009). Management of patients presenting with acute psychotic episodes of schizophrenia. CNS Drugs. Retrieved from Capella
Van Os, J., Kenis, G., & Rutten, B. (2010). The environment and schizophrenia. Nature. Retrieved from Capella
Wykes, T., & Callard, F. (2010). Diagnosis, diagnosis, diagnosis: towards DSM-5. Journal of Mental Health. Retrieved from Capella