Name: James E. Roberts Course: CMSW 1313 Date: 11/24/10 Master Treatment Plan Person’s Name: Edward Kojak Date of first visit: 10/15/10 I. Identified Problems: Primary Problem: Bipolar II disorder Secondary Problem: Poly-substance in remission Tertiary Problem: unemployed II. Historical Data: Primary Problem: Bipolar II disorder Symptoms and/or history: : Client stated he began SDTP in 2004 and spent 9 wks on an inpatient psychiatric unit while incarcerated following an episode in which he “bottomed out” following an episode of Stephens-Johnson syndrome while on tegretol in 4/08.
Described “bottomed out” to be increased isolation, hypersomnia, and nightmares. Client cited current symptoms of A/VH, nightmares, isolation, hypersomnia. Reported approximately every 7-10 days he will go through a depressive episode characterized by suppressed appetite and decreased hygiene. Client also reported instances in which the AH will become so loud and overwhelming he becomes “agitated”, most recently occurred on the bus last week. Suicide attempts in the past year: None Psychiatric hospitalization in Texas Department of Criminal Justice from 2/08-2/09 for evaluation and treatment of mood disorder (bipolar1) Treated as an outpatient for major depression in SDTP in 2005. Currently treated for bipolar disorder at MHMRA. Secondary Problem: Poly-substance in remission? ) SUBSTANCE ABUSE/DEPENDENCE HISTORY: Substances used Alcohol: last drink was 08/05. Client approximated date of last use. Client reported having abused tequila most often. Also reported abusing valium and Boone’s farm while in the military following a back injury. Opiates: last used on 08/22/05.
Client reported having last used opiates on the above date when he attempted to hurt himself by overdosing on lortabs and other pills. Cocaine; last used on 08/05. Client approximated date of last use. Client reported having used crack cocaine & powder cocaine. Amphetamines; last used on 1988. Client approximated date of last use. Cannabis; last used on late 1980s. Client approximated date of last use. Client reported having smoked primo (mixture of crack cocaine and marijuana or tobacco) in the late 1980s. Sedatives/hypnotics (benzodiazepines/barbiturates): last used on 2005.
Client approximated date of last use. Nicotine; last used today. Client reported he smokes approx. 20 cigarettes per day. History of substance dependence treatment; Client stated he attended SDTP from 2004-2005 and recently began again in 9/09. Client also reported being involved in a substance dependence unit in prison from 3/05 to 12/05. No History of medically-complicated substance withdrawal; Was in residential drug treatment program (Lieutenant’s House) in 2004/2005 Also had 9 month long hospital drug treatment program in 1995 while incarcerated. Tertiary Problem: unemployed
Client has difficulty obtaining employment due to criminal background and inconsistent employment history. Client also seems to experience problems with socialization skills. III. Functioning: Somewhat adequate – client has some difficulty solving certain problems. Has a hard time understanding appropriateness of his thought/actions. IV. Problem Objective: Primary Problem Objective: A. Goal 1: to experience symptoms for shorter durations. B. Goal 2: to report no racing thoughts, clear/logical thinking and no anxiety daily for two months. Secondary Problem Objective: A.
Goal 1: maintain sobriety from alcohol and/or street drugs by participation in six month structured treatment program. B. Goal 2: Identify and apply coping skills to maintain sobriety. Tertiary Problem Objective: A. Goal: Participate in work training program. B. Goal: Find and maintain suitable work. V. Treatment Technique: The recommended treatment for problem # 1 is: Through person-centered therapy – follow the Mental Health Treatment Plan, including taking meds as prescribed, and attend all scheduled appointments for individual and group therapy. Attend doctors’ appointments monthly for a medical evaluation.
Report symptoms immediately. The recommended treatment for problem # 2 is: Through Gestalt therapy – Learn to recognize substance abuse as reason for daily living challenges. Participate in a Substance Dependence Rehabilitation (SDRS) program. Attend substance abuse group 1-4 times a week to learn negative effects of substance abuse. The recommended treatment for problem # 3 is: Through Cognitive behavior therapy – participate in the Work for Pay program for at least 90 days or until satisfactory improvement is noted in work habits and skills as evidenced by: a.
Increased productivity – complete assigned tasks and increase earnings to a minimum wage level or above. b. Work place tolerance – attempt to work up to 32 hours/week on a regular basis. c. Dependability – fulfill assignments in a reliable and timely manner and be punctual for work. d. Supervision- accepts direction and instruction appropriately. e. Interpersonal skills/teamwork – demonstrate the ability to get along with others. f. Personal appearance – maintain a neat appearance and good personal grooming. g.
Awareness and practice of safety – adhere to safety rules, lift properly, wear protective devices as needed and display good common sense on the work-site. h. Responsibility – attend and participate in all required meetings and hospital appointments. VI. Family involved in treatment: Will be limited as Mother is moving out of town and no other relatives nearby. VII. Identify any unusual treatment complications. Client complaints that he gets easily frustrated and can be irritable. VIII. Estimated duration of time and number of visits for each identified problem up to termination of service.
Each estimation must logically and clinically match the problem. Estimated duration for Problems #1: Ongoing as described in recommended treatment for disorder. Estimated duration for Problems #2: Ongoing as described in recommended treatment for disorder. Estimated duration for Problems #3: Vocational Rehabilitation process components available for initial period of six months; at which time an evaluation of progress occurs for further services. Case management meeting, individual counseling and peer group attendance are each bi-monthly appointments.