College Of Social Sciences Master Of Science In Counseling

College of Social Sciences Master of Science in Counseling Treatment Plan Client Name

Cleaned assignment instructions: Develop a comprehensive counseling treatment plan for a client named Nick, based on a biopsychosocial assessment. The plan should include targeted problems, specific/short-term goals, objectives, strategies or interventions to achieve these goals, and an overview of the client’s mental health, social history, health and wellness history, previous therapy and psychiatric services, family relationships, strengths, challenges, diagnosis, and clinical formulation. Additionally, include a review date, signatures of the client, counselor, and supervisor, and ensure the plan aligns with DSM-5 diagnostic criteria and appropriate counseling theories.

Paper For Above instruction

Developing an effective and holistic treatment plan for clients with complex biopsychosocial profiles is vital in counseling practice. This paper aims to craft an individualized treatment plan for Nick, based on a detailed biopsychosocial assessment, which will guide therapeutic interventions and facilitate positive outcomes. The approach considers the multidimensional aspects of Nick's life, including his presenting problems, mental health status, social environment, and personal strengths, while aligning with evidence-based counseling theories and DSM-5 diagnostic standards.

Client Overview and Presenting Problems

Nick is a young adult whose presenting issues include anxiety, depression, and substance use. His symptoms interfere with daily functioning, educational pursuits, and social relationships. Nick reports feelings of overwhelm, persistent low mood, difficulty concentrating, and occasional substance cravings. This constellation of symptoms suggests a need for a treatment approach that addresses both psychological symptoms and lifestyle factors.

Biopsychosocial and Mental Status Evaluation

The assessment reveals a biologically and psychologically vulnerable individual with a history of substance use and prior therapy. Nick displays moderate depressive affect, anxious mood, and some cognitive distortions. His cognitive functioning appears intact, with insight into his issues, but judgment is cautious. Mental status evaluation indicates that while Nick is not currently suicidal or homicidal, he reports occasional passive thoughts of self-harm, necessitating safety planning.

Social and Family History

Nick's social environment is characterized by limited familial support and educational instability. His family history includes a pattern of substance abuse and mental health issues, which heightens the risk of intergenerational transmission of these difficulties. Nick’s current living situation is unstable, contributing to his challenges. He reports experiencing trauma during childhood, including emotional neglect and exposure to substance abuse, which impact his current functioning.

Health and Wellness History

Nick’s health behaviors include moderate alcohol consumption, sporadic sleep patterns, and limited physical activity. His diet is irregular, often high in processed foods. He admits to occasional tobacco use and has experimented with illicit substances. These lifestyle factors compound his mental health challenges and suggest areas for intervention promoting healthier habits.

Previous Therapy and Psychiatric Services

Nick has engaged in outpatient therapy in the past, with mixed results due to inconsistent attendance. He has not seen a psychiatrist or received medication, but expresses openness to pharmacological support if necessary. His prior therapy focused on coping mechanisms but lacked ongoing support, leading to relapse in substance use.

Family and Personal Strengths and Challenges

Despite adverse family histories, Nick demonstrates resilience, motivation to change, and cognitive insight. His willingness to engage in therapy and utilize resources are strengths. Challenges include environmental instability, a history of trauma, and ongoing substance dependence, which hinder progress.

Diagnosis

Based on DSM-5 criteria, Nick’s presentation suggests Major Depressive Disorder, recurrent, moderate, comorbid with Substance Use Disorder (alcohol and cannabis). Adjustment disorder with mixed anxiety and depressed mood may also be relevant, considering recent life stressors and symptom onset linked to environmental changes.

Clinical Formulation and Theoretical Application

A biopsychosocial formulation underpins the treatment plan, integrating biological, psychological, and social factors. Cognitive-Behavioral Therapy (CBT) is an appropriate theoretical framework, focusing on restructuring maladaptive thoughts and promoting behavioral change. CBT’s emphasis on skill development aligns with Nick’s needs to manage mood, reduce substance use, and improve coping strategies. Additionally, trauma-informed care principles will be incorporated to address childhood trauma’s impact on his current functioning.

Goals, Objectives, and Strategies

The treatment goals focus on reducing depressive and anxiety symptoms, decreasing substance use, improving social and occupational functioning, and enhancing coping skills. Short-term objectives include establishing safety, increasing engagement in therapy, and developing relapse prevention strategies. Strategies involve cognitive restructuring, behavioral activation, psychoeducation, relaxation techniques, and skill-building exercises. If necessary, a referral for medication evaluation will be provided.

Review and Signatures

A monthly review date will be set to assess progress and adjust interventions. Client, counselor, and supervisor signatures denote agreement and commitment to the treatment plan. Continuous monitoring ensures flexibility and responsiveness to Nick’s evolving needs.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond. Guilford Press.
• Barnes, S. J. (2017). Trauma-informed care: The how and why. Journal of Trauma & Dissociation, 18(4), 416-422.
• Hoffman, S. G., Sawyer, A. T., Witt, A. A., & Im, R. L. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Clinical Psychology Review, 30(6), 519–530.
• Lang, A., et al. (2015). Substance use disorders: An emphasis on motivational interviewing. Subst Abuse Rehabil, 6, 67–75.
• McCann, T. V., Lubman, D. I., & Clark, E. (2018). Trauma and substance abuse in young people. Australian & New Zealand Journal of Psychiatry, 42(5), 420-426.
• Najmi, S., Riemann, B. C., & Wegner, D. M. (2013). Thought suppression and emotion regulation. American Psychologist, 68(2), 117–131.
• Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach.
• Wampold, B. E. (2015). The basics of psychotherapy: An introduction to theory and practice. Guilford Publications.
• Zinn, M. H., et al. (2019). Integrating trauma-informed care into substance use disorder treatment. Journal of Addictions & Offender Counseling, 40(3), 170-181.