Treatment Plan

Treatment Plan

Description of Client:

Alexandria Wright is a 36-year-old Caucasian female who appears older than her stated age. She was well groomed, average height, and overweight. She was respectful and cooperative throughout the interview; however, at times she did appear defensive. She is married and has two sons ages five and seven. Her parents are both deceased with her father passing away a year ago. Alexandria also has three sisters with a three-year gap between them. She is also highly educated and works as a Certified Public Accountant.

Presenting Problem:

Recently, within the last month, she has had a return of the feelings of sadness present after her father death a year ago. According to the client, she is experiencing this recurrence because of issues associated with her father’s estate.

History of Problem:

Alexandria reported having been in psychotherapy a year ago after her father’s death, and reported that it helped her. However, in the last month she has been dealing with settling her father’s estate, and it has brought back the feelings of sadness. She describes her sadness as feelings of annoyance, especially toward others. Although she initially reported sadness as her primary issue she quickly shifted the focus to family problems that months ago were not present. According to, Alexandria the family problems began as soon as, at the request of her father, she started functioning as the executor of her father’s estate. She also reported that besides being assigned the executor of her father’s estate his wish was that the family divided everything equally to prevent any family discord. To ensure aforementioned occurred she and her siblings decided they would prohibit their spouse’s involvement and input in their father’s estate.

Despite the agreement made she has been experiencing interference from her brother in-law Bruce. She reports he is not in agreement with the value and prices she has placed on her father’s belongings. This is causing her to feel agitated, annoyed, unappreciated, and insulted. It also has caused them to argue and have conflict between them. According to Alexandria these feelings stem from having invested a large amount of time and effort placing value on her father’s belongings. She also believes he is criticizing her ability to handle being the executor of the estate even though she is an accomplished certified public accountant (CPA).

Additionally, this has caused conflicts with Bruce’s wife Elizabeth, who is her younger sister. She believes Elizabeth should put a stop to his interference and criticism, and by not doing so is choosing Bruce over the agreement they made. She also believes Elizabeth’s behavior is inappropriate at times because of her impulsivity, spontaneity, and growing up with no boundaries or guidelines. Thus in effect causing her to be upset and irritated with Elizabeth.

Mental Status:

Her eye contact was good. Her affect was appropriate to the context and situation. She was oriented to person, time, and place. Her motor activity was overly calm. Her attitude was cooperative and focused; however, easily defensive. Her speech was coherent and of normal rate, rhythm, and tone. She also reported no past or current history of suicidal or homicidal ideations or plan and intent. She did not experience visual or auditory hallucinations. Insight and judgment appears within normal range. Thought content was free of phobias, delusions, and ideas of reference.

Social History:

Alexandria reported having a normal childhood with nothing unusual occurring. Her parents had clear expectations and rules, and they had high expectations for her. Despite their rules and high expectations she had a good relationship with them. She was well organized and a responsible child. She was also very tidy, clean, and liked order. She also grew up with three sisters with a three-year gap between them. Alexandria reported that they were named after royalty, and her parents treated them as such. She was closest to the oldest sister because they had many things in common. This close relationship continues to hold true as adults. Alexandria reported some of her proudest achievements included becoming her high school valedictorian, graduating magna cum laude for both her bachelors and masters degrees, and getting her CPA on the first try.

Currently, she is married and has two sons ages five and seven. Her husband is an automotive engineer and her children attend elementary school. She has a CPA and currently works as an accountant. She describes her life as very organized and structured. For instance, they get up every day at the same time, eat at the same time, clean their home every Monday, do laundry only on Tuesdays, and she helps her children with homework the same time every day. Financially they follow a strict budget and always save 10% of their income for their son’s college education and emergencies. According to Alexandria, life is easier having structure and order. Even though she reports the need of having structure and order she denied engaging in rituals, procedures, or obsessive thoughts.

Alexandria also reported that she organizes for fun and organizing relaxes her. For instance, when on family vacations she finds herself organizing the kitchens in her vacation homes. Additionally, at times when organizing it is hard for her to stop intrusive thoughts; however, she is always able to complete the task. She also stated she is a hard worker not a perfectionist; however, her sisters tell her she is a perfectionist. For example, when planning a family vacation she will spend a significant amount of time organizing and structuring the trip to the point of annoying her family. She also will not consider delegating tasks because of the belief that no one can do as well as her. She reported concerns about her children’s education because of inappropriate societal influences. She believes society has taken a nose dive for the worse and would like to control what her children learn in regard to morality and values. In fact, this belief has caused her to consider home schooling her children.

Strengths and Assets:

Alexandria is a hard worker, is self-disciplined, and motivated to treatment evidenced by her self-referral. This motivation and insight as well as her self-discipline and work ethic will prove beneficial in the implementation of goals and interventions. She is also assertive, which in client driven and collaborative therapeutic modalities will be a strength.

Diagnosis:

Axis I: 309.0 Adjustment Disorder with Depressed Mood, Acute

Axis II: 301.4 Obsessive-Compulsive Personality Disorder

Axis III: None

Axis IV: Problems with primary support group-discord with brother-in-law/sister

Axis V: GAF 61 (present)

Diagnostic Rationale:

Alexandria meets the criteria Axis I 309.0 because substantial criteria indicators are met. The indicators are as follows: She developed the emotional symptoms (sadness, annoyance) in response to the stress of pricing her father’s belongings within three months of beginning this task. This annoyance and sadness is in excess of what would be expected from exposure to this new stress in her life (her brother-in-law interfering with the estate). Additionally, this is causing her significant problems interpersonally with her sister and brother in-law. Last, with the information gathered, she did not meet the criteria for any other mood disorder or bereavement disorder because her symptoms are not related to mourning the loss of her father.

She meets the criteria Axis II 301.4 because four or more of the criteria indicators are met. They are as follows (1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent the major point of the activity is lost, (2) is over conscientious, scrupulous, and inflexible about matters of morality, ethics, or values, (3) is reluctant to delegate task or work with others unless they submit to exactly his or her way of doing things, (4) adopts a miserly spending style toward self and others; money is viewed as something to be hoarded for future catastrophes, and (6) shows rigidity and stubbornness.

Treatment Plan:

Mode:

With adjustment disorder the goal of therapy would be to have Alexandria return to the level of interpersonal functioning prior to the conflicts associated with the estate. Also to change the maladaptive thoughts or behaviors she is using to respond to her current stressor. In terms of the obsessive-compulsive personality disorder the target would be Alexandria’s need to organize (behavior) to feel a sense of control (feelings). The premise of Cognitive Behavioral Therapy (CBT) is the link between a person’s thoughts, feelings, and behaviors, thus I would recommend this approach for Alexandria.

Frequency and Duration:

CBT is recommended weekly. The sessions would be one-hour long for 12 to 14 weeks.

Referrals:

1. Referral to psychiatrist for an evaluation to determine appropriateness of medication for symptom management.

2. Referral to her primary care physician to rule out any medical condition that could be causing the sadness, such as a thyroid problem or diabetes.

Goals of Treatment:

Short-Term Goals:

1. Will reduce arguments with brother in-law Bruce and sister Elizabeth from seven times a week to five times a week.

2. Will improve coping and problem-solving skills to reduce stress when confronted with a new problem or challenge.

3. Will engage in one pleasant activity a week that does not consist of organizing or scheduling.

4. Will decrease episodes of organizing and structuring from seven days a week to five days a week.

Long-Term Goals:

Will restore positive interpersonal relationships with her brother-in-law and sister to the previous (one year ago) level.

When faced with a new problem, change, or challenge will display effective coping and problem-solving skills.

Will be able to engage in three pleasant activities a week that does not consist of organizing or scheduling.

Will decrease episodes of organizing and structuring from seven days a week to once a week.

Interventions:

To improve Alexandria’s relationship with her brother in-law and sister interventions provided would be:

First increase her awareness of her behavioral responses in the relationship, her role in the conflicts as well as their interpretation of her behaviors.

Assist in identifying inappropriate responses by having her journalize her interactions and feelings when interacting with Bruce and Elizabeth.

Practice appropriate verbal and behavioral responses to a variety of anticipated situations via the use of role-play.

To improve her coping and problem-solving skills interventions provided would be:

Teach her to identify what she has control over and what she does not.

Educate on effective problem-solving techniques.

To increase her pleasant activities the interventions provided would be:

Help her identify activities she could participate in that do not consist of organizing and scheduling.

Use a calendar to have Alexandria schedule in the day of the week she will do the activity.

Teach her the link between pleasant activities and the decrease in her stress as well as sadness.

To assist in helping decrease her episodes of organizing and structuring interventions would include:

Use the cognitive triangle technique to teach how her thoughts about orderliness and cleanliness are affecting her behavior.

Implement the thought stopping technique to assist in the reduction of the obsessive behavior and thoughts.

Implement the deep breathing technique so she can relax and self-soothe while attempting to decrease the obsessive-compulsive urges and behaviors.

Prognosis:

Alexandria’s prognosis is good because she not only has the motivation for treatment but also has the cognitive ability to understand the interventions that would be provided in session. Ultimately, treatment outcome will not solely depend on the recognition that a problem exist but also relinquishing some of that control despite the emotional stress it will cause.

Person of the Therapist:

The therapist recommended neuro-linguistic programming despite the fact the he was not competent in this technique having attended only one seminar. As therapist we cannot treat or use interventions beyond our scope of practice or competencies. During this session the therapist exposed himself in transference by saying he knew who Bruce was and even mentioned his last name. The therapist told the client he work in the same company and even shared personal information about Bruce. Therefore, the client felt in her confront zone and asked the therapist to speak to Bruce and tell him to maintain away from her business. Even though the therapist stated he could not do that because it was unethical this can still have some ethical or legal concerns as it can cause a dual relationship or even risk breaking confidentiality laws. In this situation I would have asked the client if she had a problem with me as her therapist because I knew her brother in-law. If she did have a problem I would transfer the case to prevent a multiple or dual relationship. If it was not a problem I would reinforce confidentiality as well as setting clear boundaries.

Also, the therapist interrupted the client numerous times. For instance, he consistently interrupted to make inferences of what she was feeling, what she did or said. Even though summarizing of feelings is an appropriate therapeutic technique he did not reflect the clients feelings effectively.

I would also have liked the therapist to obtain more information on the client’s sadness to assist in ruling out a mood disorder as well exploration of indictors of associated with bereavement. It also would have been helpful to explore impairments in an area of life functioning other than socially/interpersonally. For example, it was not clear if her extreme organizing is affecting her at work, with her activities of daily living, or with her physical health. It is assumed with the limited information we obtained she is not. He also never asked about substance abuse, legal history, mental health history, explored culture factors, or assessed for trauma.

Reference

American Association for Marriage and Family Therapy (AAMFT). (n.d.). Code of Ethics. Retrieved from http://aamft.org

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed; text rev.). Washington, DC: Author.