Example of a Mental Health Assessment and Treatment Plan

Example of a Mental Health Assessment and Treatment Plan

 

Case # 2 – Ryan

 

Diagnosis (using the DSM-IV-TR):

 

Axis I: 304.10 Sedative, Hypnotic, or Anxiolytic Dependence, without physiological dependence

Axis II: V 799.9 diagnosis deferred R/O 312:89 Conduct disorder; R/O 301.7 Antisocial Personality Disorder

Axis III: V 799.9 diagnosis deferred

Axis IV: inadequate social support, discord with others, problems with the legal system, 

Axis V: GAF Score 40

Axis I - Symptoms: When seventeen years old, Ryan reported to a clinician completing a psychiatric evaluation, in a psychiatric hospital, that he “loved PCP or angel dust, and that he would rather be dusted than anything else.” He explained that he would take routine trips to ‘New York City to buy drugs.’ He denied any feelings of ‘nervousness.’ Clinician notated that “This wasn’t machismo; he really seemed unconcerned.” He was discharged from the psychiatric hospital into a drug rehabilitation program. This turned out to be an unsuccessful effort to cut down or control Ryan’s substance use. Clinician notated that Ryan convinced his parents to take him home within four weeks, and Ryan stole his parent’s money and disappeared to go back with his friends and drugs. A few years later, the clinician reports that Ryan has been arrested several times for theft, and that he continues to con his parents for money to buy drugs. Ryan, and the information present, does not report any evidence of tolerance or withdrawal. Ryan’s diagnosis is without physiological dependence: no evidence of tolerance or without withdrawal is present. The Addiction Severity Index will measure predictors of substance dependence, and Laboratory tests are a good screening tool and detector of continual use.

Axis II - Symptoms: Ryan’s records indicate that he was truant from school for several months, at the time he was seventeen, and he was in legal trouble. Ryan accompanied other teenagers to the local cemetery to perform satanic rituals, and a “young man was stabbed to death.” Ryan admits to being at the scene, but he denies stabbing the boy. Ryan admitted to stealing skulls from the graveyard for parties. No emotional concern was displayed by Ryan according to the clinician. No other past information is in the record; as such, the diagnosis is being deferred until records or information is received to do a complete history. Records should include bio psychosocial, medical, educational records, and any history of behaviors that would be abnormal or illegal if performed as an adult or caught. Ryan has a history of doing ‘many’ things that he claims to regret, but the Psychiatric notes state that “he was never truly remorseful for anything.” During the 48 hours that he was monitored and evaluated, the hospital documented ‘several things’ that showed Ryan needed help. Ryan told another patient that he was going to get released, get in trouble, and be sent to prison where this client’s father was. He threatened to rape the patient’s father. This caused the patient to get upset and hit others at the hospital. When confronted about his actions, Ryan explained that “he was bored and that it was fun to upset Ann.” Ryan went on to state, “Why should it bother me? She’s the one who’ll have to stay in this hellhole!” A complete structured interview would confirm or rule out a conduct disorder and antisocial disorder. Ryan can be assessed by administering objective tests of antisocial behaviors, impulsivity, and aggression. 

 

Axis III - Symptoms: The medical diagnosis is being deferred until information is gathered to determine his medical history. An up to date Physical should be performed on the client, because of his repeated drug use. 

Axis IV – Problems or Stressors: Ryan does not have an adequate social support system. His parent’s continue to provide him with a way to buy drugs. He has a history of discord with others, and he lacks empathy for the things that he does to them. He has had numerous problems with the legal system: he has been arrested several times for theft, and he was arrested at seventeen.  

Axis V: GAF Score 40. Ryan has major impairment in several areas of his life.

Potential Causes of this condition/disorder: This is based on the current information that was provided; however, more information needs to be obtained.

Ryan displays antisocial personality traits, and a complete history of childhood behavior should be reviewed to determine if he had a conduct disorder, and currently has an antisocial personality disorder. Dramatic Personality disorders are general caused by family-based stressors and genetic predisposition.

Ryan’s substance dependence is likely due to his personality and Psychopathy. His lack of remorse, need for immediate gratification, and antisocial behaviors. Risk factors that might have played a role in this are deviant peers and initial drug experiences.

Treatment Plan: Referral to a psychiatrist for medications. 

Social Problem Skills and Cognitive Behavioral Therapy – Two visits per week (one individual, one group). Ryan needs to take responsibility for his behaviors, and the effect that they have on others. He would benefit from learning how antisocial behavior is self-defeating, and developing effective coping skills to self-monitor. In one year, Ryan’s progress can be assessed by re-administering objective tests of antisocial behaviors, impulsivity, and aggression to determine if progress has been made and if treatment should be decreased.

Ryan needs to develop a program of recovery that is free from addiction. Ryan’s initial treatment should be in-patient, and then he can transfer to a half-way house, and outpatient care.

Why are Young Women Cutting (Self-Injury)?

There is not a lot of research on self-injury among young women; nevertheless, the research that has been done normally only includes women that are 18-26 years old and not younger. Self-injury is more common in women than men; therefore, this paper will focus on women but the information applies to men as well. “Self-injury typically occurs within the age range of 13-23,” because this is when they are developing (p. 76). According to Laurie Craigen and Victoria Foster, “the act of self-injury may be a means of expressing feelings of discontent and anger and a form of psychological resistance articulating a need to be heard and to be taken seriously” (p.77).

It would benefit young women if the research was conducted targeting them when they start the self-injury, because self-injury among young adults is on the rise. Due to a lack of empirical date, it appears that this type of behavior is resistant to treatment (p. 77). Therefore, the article discusses the helpful and unhelpful behaviors the counselor does demonstrate during their sessions with their client. It also discusses the counseling process, and the counseling reflection. The data suggest that, “the most helpful counseling did address these issues” referring to the underlying issues that triggered the self-injury (p.89).

The study provides an accurate picture of individuals that self-injure, because it takes the time to speak to the individuals and ask them about their counseling and the treatment that they received. The study gathered information through qualitative interviews. The research provides insight for counselors that work with clients that self-injure, because the results show that helpful behaviors displayed by counselors were “respectful listening, understanding, and acting as a friend” (p.82). The results of the data help to educate the counselors, so that they focus on the ‘underlying issues’ through talk therapy. The article made a very good point that if you ignore the underlying reasons behind the cutting, then you are not addressing the needs of the clients. The counselor needs to find out why the client is hurting themselves, and they can do this by asking questions. For example, they could ask “If your wounds could speak, what would they say about you? What are your wounds trying to communicate? What feelings drive you to self-injure? What wounds exist beneath your scars?” (p.91). The counselor needs to be nonjudgmental when responding in order to develop the counselor-client relationship.

The participants were ten woman aged 18-23, and that limits the information that was received through the interviews. Ten participants is not a lot of people, and the participants do not give any insight into counseling experiences of young girls – girls that start to cut prior to 18. More studies need to be done to determine what strategies are effective in treating clients that self-injure, because an effective treatment plan needs to be developed.

 I believe the study would have been better if the participants ranged from 12-23, and if it focused on gathering data from multiple types of therapy. For example, is Dialect Behavior Therapy (DBT) being used as a treatment for young women that self-injure? Is DBT impacting clients that self-injure? How is it impacting them? What would the data show if the research was done? The data is unclear about the treatment approach, and that is a problem, because the number of people that self-injure is on the rise and it is important to have evidence/data that will support the best way to treat the individuals that self-injure.   

My daughter has been cutting for almost two years now, and the information for families is not very comforting or helpful. I have been told she is just trying to manipulate me, and I have been told that she wants attention. I know that she has not cut in a few months, but that is because we have an agreement – if there are no marks she is allowed to be alone (because that is when she cuts), but if she cuts then she needs us (her family) around 24/7. The door to her room cannot be closed, and I check on her when she uses the restroom. I don’t know if it is the right thing to do or the wrong thing to do, and the experts have given us conflicting messages. But, I know that it is hard to do nothing when your child is hurting themselves. My daughter is talking to me more about the thoughts that trigger her to cut, and we made a poster of positive affirmations to counter act the negative thoughts. It is posted on the back of her door. She says that, “I am annoying” and she thinks about losing her privacy when she has the urge to cut and it has helped.

We made tool-kits together, so we could use them if we needed them. She took mine out of my room and as she brought it into hers, she commented “I need it more than you do!” However, I think she liked the tools in my kit (classical music, candles, breathing exercises, and permission slips: Permission to write down the thought and to talk about it at a later time, in a safe place). 

 

Reference

Craigen, L. M., & Foster, V. (2009). "It Was like a Partnership of the Two of Us Against the Cutting": Investigating the Counseling Experiences of Young Adult Women Who Self-Injure. Journal Of Mental Health Counseling, 31(1), 76-94.