CNL 610 Week 8: Eliza Discharge Summary
Client Goals
Eliza met the goals of the second treatment plan. Unlike the initial treatment plan, which was not effective, the week seven (7) treatment plan goals were achieved. Eliza’s revised treatment goals were to be free of alcohol abuse, increase the ability to manage anger, and to embrace non-resistance behavior and thought patterns (Schwitzer & Rubin, 2015). To formulate these treatment goals, despite the initial treatment goals, Eliza still presented with alcohol dependence, uncontrollable anger/mood swings, resistance behavior, low self-esteem, and blame game habit as she defended herself. In this treatment plan, treatment interventions were revised to improve Eliza’s treatment goals’ validity and effectiveness. By the end of the session, Eliza had achieved the treatment goals by:
- Learning three positive anger/mood management skills
- Being able to get through a whole week without angry mood behaviors
- Gaining a great sense of reality
- Gaining two structured skills of problem solving and avoiding alcohol dependence/abuse
Also, Eliza’s goals were achieved by reducing the frequency of therapy to both weekly and bi-weekly, combining individual, group, and family modality of treatment, and utilizing new interventions, i.e., CBT/cognitive restructuring, reality therapy, exercising, and mindfulness training (Young, 2007).
Reasons for Treatment Plan Success
It is clear that the initial treatment plan was a failure due to Eliza’s continued abuse of alcohol, distress, resistance behavior, mood swings or anger issues, and more. A change of treatment goals, objectives, and interventions is thus the main contributor to the second treatment plan’s success, i.e., CNL-610: Topic 4 and 7 Treatment Plan. Eliza’s treatment goals were changed to mainly address her alcohol dependence, resistance behavior….
Communicating Treatment Outcome
To communicate treatment outcomes to Eliza, the client needs to use a language that Eliza understands best; this would help avoid the communication barrier. However, for Eliza to respond to the treatment outcomes positively, the counselor has to ensure a positive rapport or relationship with the client (Eliza). Also, when communicating with Eliza, the counselor needs to be culturally sensitive and avoid imposing his/her own opinions on Eliza’s cultural values, norms, beliefs, and thought patterns (Young, 2007). This means that the counselor would be friendly and pay attention to his/her tone of voice, practice active listening, and be consistent to ensure that Eliza understands and is able to practice the skills learned….
Final Session Documentation
Eliza’s final session would be documented by creating a client contact sheet, file creation, digital folder creation, and adding her client tracking number to the practitioner’s client database. Eliza’s assessment procedures, diagnosis, treatment planning, and prognosis will be documented in a physical file and stored by the clinician (Young, 2007). This information would be used in writing Eliza’s discharge summary. In case a referral is needed, this information will be referenced to write a referral to another counselor. Also, Eliza’s treatment records’ well-documentation would support the counselor in delivering a high standard of care. Besides, well-kept client records would help the counselor maintain a reliable history of crucial information relating to Eliza’s treatments, behavioral health, relevant life events, rather than relying on memory.
References
- Leichsenring, F., Salzer, S., Beutel, M., Herpertz, S., Hiller, W., & Hoyer, J. (2014). LongTerm Outcome of Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder. American Journal of Psychiatry, 171(10), 74-82.
- Schwitzer, A., & Rubin, L. (2015). Diagnosis & Treatment Planning Skills. Thousand Oaks: Sage.
- Young, K. S. (2007). Cognitive behavior therapy with Internet addicts: treatment outcomes and implications. Cyberpsychology & Behavior, 10(5), 671-679.