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After reading the following case study, you will need to determine…
After reading the following case study, you will need to determine the client diagnoses, with code and specifiers. You will need to write out the justifications for why you selected the diagnosis (i.e., provide evidence/justification from information in the case study). Additionally, you need to provide a differential diagnosis for each identified diagnosis. After you have established your diagnoses, complete the treatment plan provided below (make sure to complete the entire treatment plan: 2 presenting problems, 2 goals, 2 objectives per goal, 2 interventions per objective).
One of the objectives MUST address suicidal assessment. You must identify minimum 2 Z(V) codes for this client.
You, as an outpatient agency counselor, are given the following information:
Rhonda is a 28-year-old female who has been referred to your agency by a local probation officer. Rhonda reported that she has “fired” three counselors in the past and most recently was “kicked out” by her counselor at a local community agency. Rhonda stated that the reason she “fired” her previous counselors is that they were “clueless and didn’t get me.” She states that she thinks her most recent counselor “kicked me out because I threatened to kick him as if he didn’t back off.” You note that she is smiling as she repeats the threat she made to the previous counselor. She then lets you know that she is currently on probation for alcohol use and her “anger issues.”
Rhonda states that she is looking for a counselor who can “handle my past and actually knows how to help me get over it.” Rhonda then proceeds to tell you she had 19 surgeries before the age of 10 to resolve a generic heart defect. She reports that she continues to be under the care of a cardiologist because her heart condition will continue to be an issue throughout her life. Rhonda reports experiencing significant anxiety whenever she drives by a hospital or has to go into a hospital to visit friends.
During the first 10 years of Rhonda’s life, she was sexually abused by a neighbor. Rhonda reports that she was also sexually abused by her sister during the same period and continued until her sister moved away to college. Rhonda was 16 years old when the sexual abuse from her sister stopped. Rhonda disclosed to her mother the abuse she experienced from the neighbor and her sister shortly after the neighbor was charged with sexually abusing another child in the neighborhood. Rhonda’s mother stated that she did not believe that Rhonda’s sister has abused Rhonda because “I am a good mom and would have known if something like that was happening under my roof.” However, her mom did believe Rhonda’s disclosure of sexual abuse by the neighbor but felt there was no need to report Rhonda’s abuse when the neighbor, who had already been charged for abusing a different child in the neighborhood, would be going to jail in any case. Rhonda states that her relationship with her mother has been “hot and cold” ever since Rhonda disclosed the abuse.
She also reports that she is unsure whether her father is aware of the abuse she endured from the neighbor and her sister; Rhonda never disclosed this information to him directly, but she suspects her mother would have told him. The family never discussed Rhonda’s disclosure of sexual abuse and Rhonda does not know whether anyone ever confronted her sister about the abuse. To date, Rhonda has never talked to her sister about it and avoids most family gatherings that she expects her sister will attend. Rhonda states that she regularly gets high if she finds herself at family gatherings that her sister is attending.
Rhonda reports that she continues to have flashbacks of different episodes of abuse. She identifies her heart surgery scars as a trigger. She states that when her scars are touched by anyone, including herself, she gets flashbacks of the sexual abuse by her neighbor because his large hands would brush over her scars when he was fondling her breasts. She also identifies the smell of a particular lotion to be a trigger of the abuse she endured from her sister. She states she is still unable to tolerate the smell and texture of any lotion and has never bought a bottle of lotion as an adult.
Rhonda is currently unemployed but is looking for a job. She reports that she has a difficult time maintaining employment because she moves around a lot. When asked what causes her to move around a lot, she reports that she has had a few relationships (six in the last year) that did not work out well and that she was living with each of them at the time of the breakups. Rhonda states that she is currently “trying on” being a lesbian because she believes that “women are more understanding than men, so maybe a woman would get me better and not leave me.” Rhonda that she struggles to manage her money or maintain any relationship stating that “most people in my life end up leaving me.”
When asked what she had been working on with previous counselors, Rhonda states that she had been working on different coping skills. In the past, Rhonda would harm herself or get high when her trauma was triggered. She states that she now tries to engage in deep breathing and relaxation techniques, but “they aren’t as effective as burning myself.” Rhonda does report a history of suicidal ideation and identifies that she typically will feel suicidal when her romantic relationships are ended by the other person. Although Rhonda reports a history of suicidal ideation, she reports no attempt to take her life.
Rhonda is coming to counseling to be in compliance with her probation. She is currently working on substance abuse issues with another counseling agency. She had been clean and sobor for 6 months. Rhonda is coming to your agency (outpatient setting) with the hopes to work on her past sexual trauma. She states that she believes sexual trauma is the root of her anger, relationships problems and substance abuse issues. She believes that if you can just “make the bad stuff in my past go away” she will be able to get off probation and stay out of trouble.
Diagnoses: _________________________________________________________
J justification:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Dif diferential Diagnoses: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Treatment Plan
Problem/Concern #1:
Goal #1:
Treatment Objectives Interventions Expected Date
1a. 1.a.i
1.a.ii
1b. 1.b.i
1.b.ii
Problem/Concern #2:
Goal #2:
Treatment Objectives Interventions Expected Date
2a. 2.a.i
2.a.ii
2b. 2.b.i
2.b.ii
MHS 6070: HW #2, Case Study Rubric
Student Name: _____________________________Total Score: _________________
Areas of Competency Exceeds Expectations Meets Expectations
Below Expectations
Score
Diagnosis
Correct diagnosis
20 points
Error(s) in diagnosis
10 points
Incorrect diagnosis
0 points
20
10
0
Code
Correct code
5 points
Incorrect code
0 points
5
0
Specifiers
Correct specifier
5 points
Incorrect specifier
0 points
5
0
Correct recording procedure for diagnosis
Correct recording procedure
10 points
One or more errors in recording procedure
5 points
Incorrect recording procedure
0 points
10
5
0
Problem/Concerns
Identified accurate problems/concern.
10 points
Identified inaccurate problem/concern.
0 points
10
5
0
Goal
Identified accurate goal statement.
10 points
Identified inaccurate goal statement.
0 points
10
5
0
Treatment Objectives
Identified 2 accurate treatment objectives.
10 points
Identified 1 accurate treatment objective.
5 points
Identified inaccurate treatment objectives.
0 points
10
5
0
Interventions
Identified 4 accurate interventions.
10 points
Identified accurate interventions.
2.5 points of each
Identified inaccurate interventions.
0 points
10
5
0
Expected Date
Identified appropriate expected dates.
10 points
Did not identify expected dates.
0 points
10
5
0
Suicide risk assessment (CACREP Standard 2.F.7.c)
Indicates a thorough suicide risk assessment in treatment plan.
10 points
Mentions a suicide risk assessment (but lacks specificity)
5 points
Did not indicate suicide risk assessment in treatment plan.
0 points
10
5
0
TOTAL POINTS
100
Exceeds Expectations: Demonstrates evidence of strong knowledge, skills and dispositions in this area.
Meets Expectations: Demonstrates evidence of limited to satisfactory knowledge, skills and dispositions in this area.
Below Expectations: Demonstrates little to no evidence of knowledge, skills, and dispositions in this area.
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