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Treatment Plans and Clinical Notes

Trauma Common DAPS

Data:
D: Client was referred by primary therapist for additional trauma specific treatment.
Clt reported symptoms of hypera­rousal such as
Clt identified overbo­unded boundary style.
Clt identified underb­ounded boundary style.
Asse­ssm­ent:
Clt exhibited dysreg­ulated hypoar­ousal AEB report of fuzzy vision, feeling discon­nected, numbing sensation, and difficulty thinking clearly.
Clt exhibited dysreg­ulated hypoar­ousal AEB report of tunnel vision, feeling discon­nected, numb, and far away.
Clt exhibited dysreg­ulated hypera­rousal AEB report of racing heart, the sensation of heat, intense muscle tension, and dilated pupils.
Clt exhibited dysreg­ulated hypoar­ousal AEB report of feeling "­outside of" their body.
Clt has difficulty sensing somatic experience AEB delayed responses and reporting "I don't know".
Clt exhibits cognitive distortion as a result of dysreg­ulated arousal.
Clt has inadequate relational resources to manage traumatic symptoms.
Clt has inadequate somatic resources to manage traumatic symptoms.
Clt has inadequate internal resources to manage traumatic symptoms.
Clt has inadequate psycho­logical resources to manage traumatic symptoms.
Level of Care
Clt is at risk of relapse AEB inability to regulate physio­logical arousal in response to daily stressors as a result of trauma.
Clt is at risk for relapse AEB inability to regulate physio­logical arousal as a result of past trauma without therapist interv­ention.
Clt has difficulty reporting experience mindfully AEB answering questions in the past and future tense.
Clt is making progress toward the goal of identi­fying dysreg­ulated physio­logical arousal; however, clt requires more time in treatment to meet the goal of regulating physio­logical arousal.
Clt is making progress toward the goal of regulating physio­logical arousal; however, clt requires more time in treatment to develop the ability to recount traumatic memories without dissoc­iated arousal. 
Clt requires more time in treatment to meet the goal of regulating physio­logical arousal as a result of trauma in order to maintain sobriety.
Clt requires more time in treatment to meet the goal of identi­fying dysreg­ulated physio­logical arousal as a result of trauma in order to maintain sobriety.
Clt requires more time in treatment to meet the goal of recounting traumatic memory without dissoc­iated arousal in order to develop emotional regula­­­tion, delayed gratif­­­i­c­a­­tion, frustr­­­ation tolerance, and impulse control to deal with daily stressors.
Clt requires more time in treatment to meet the goal of regulating dysreg­ulated physio­logical arousal as a result of past trauma, in order to develop emotional regula­­­tion, delayed gratif­­­i­c­a­­tion, frustr­­­ation tolerance, and impulse control to deal with daily stressors.
Clt requires more time in treatment to meet the goal of identi­fying dysreg­ulated physio­logical arousal as a result of past trauma, in order to develop emotional regula­­­tion, delayed gratif­­­i­c­a­­tion, frustr­­­ation tolerance, and impulse control to deal with daily stress­ors..
Plan:
Therapist will assist client in developing 5 somatic and 5 relational resources for regulating physio­logical arousal.
This therapist will provide individual trauma therapy 1x/week and group therapy on Trauma Symptom Reduction and Stabil­­iz­ation 2x/week. Clt will continue to work with primary therapist toward other treatment goals.
This therapist will provide individual trauma therapy 2x/week and group therapy on Trauma Symptom Reduction and Stabil­­iz­ation 2x/week. Clt will continue to work with primary therapist toward other treatment goals.
Grou­ps:
Data:
Group met to provide trauma psycho­edu­cation.
Group met to develop resources for identi­­fying and regulating physio­­lo­gical arousal as a result of past trauma.
Individual
Clt was engaged in group AEB leaning forward in chair, asking clarifying questions, and volunt­eering to do dyadic work with this therapist in front of the group.
Clt was engaged in group AEB engaging other members, asking clarifying questions, and sharing with the group that...
Plan:
Therapist will provide group therapy focused on Symptom Reduction and Stabil­ization 1x/week.
Therapist will provide group therapy on Trauma Symptom Reduction and Stabil­­iz­ation 2x/week.
Therapist will provide group therapy on Trauma Symptom Reduction and Stabil­­iz­ation 3x/week.

Common DAP Phrases

Clt is making progress toward the goal of mainta­ining sobriety; however, clt requires more time in treatment to develop emotional regula­­tion, delayed gratif­­ic­a­tion, frustr­­ation tolerance, and impulse control to deal with daily stressors.
Clt requires more time in treatment in order to stabil­ize...
Clt is making progress toward goal of ; however, clt requires more time in treatment to meet treatment goal of .
Clt is motivated by .
Clt continues to struggle with.. AEB...
Clt is at risk for ... AEB...
Clt's recent relapse has led to (insert life threat­ening experi­enc­es/­beh­avi­ors).
Clt is currently being medica­ted­/being treated for .
Clt reports Post Acute Withdrawal Symptoms such as .
Clt reports struggling with activities of daily living such as .
Clt reports changes in sleep such as difficulty falling asleep, difficulty staying asleep, and nightm­­ares.
Clt reports changes in appetite and loss of weight.
Clt reported (severe, moderate, mild) cravings.
Clt reported an increase in cravings since last session.
Clt was engaged in group AEB partic­ipating in group exercise, sharing experience with the group, and asking clarifying questions.

Justifying Level of Care

Cravings
Freque­ncy­/se­verity
Sleep
Changes, difficulty staying asleep, difficulty falling asleep, nightm­ares,
Appetite
Changes, weight loss/gain
Activities of Daily Living
Bathing, dressing, grooming, oral care, toileting, transf­erring, walking, climbing stairs, eating, shopping, cooking, managing medica­tions, using the phone, housework, doing laundry, driving, managing finances
Post Acute Withdrawal Symptoms
Emotional outbursts or lack of emotion; Anxiety; Difficulty dealing with stress; Low energy; Having a hard time sleeping, strange dreams, and changes in sleep patters; Memory proble­ms/hard to learn new things; Trouble thinking clearly, making decisions, and solving problems; Problems with balance and delayed reflexes; Feeling dizzy; Increased accident proneness
Mental Status Exam
See below

Mental Status Exam

Speech
Rapid/­pre­ssured (hyper verbal) OR soft and hesita­nt;­slu­rre­d;t­ang­ential
Judgement
Poor to Modera­te;­depends on how long client has been in treatment
Insight
Impaired; minimizes; ration­ali­zation; intell­ect­ual­izes; lacks insight
Thoughts
pre occupi­ed;­dif­ficulty concen­tra­tin­g;d­iso­rga­niz­ed;­ill­ogi­cal­;ob­ses­siv­e;f­las­hba­cks­;in­trusive thoughts
Memory
Recent memory impaired; remote memory impaired; easily distracted
Mood
Depressed and anxious; mood liability (mood swings); helpless; hopeless; impulsive; irritable; restless; agitated; apathetic
Affect
Congruent to mood; flat affect; blunted; tearful; constr­icted, blunted, Flat; Constr­icted; Inappr­opr­iate; Labile; Full range
Sl/Hi/­Psy­chosis
Per patient report; if any suicidal thoughts (passive or with plan or intent) contract for safety
Post-Acute Withdrawal
stay away from things like "­dis­ori­ent­ati­on", "­con­fus­ion­" "­vom­itt­ing­" unless client is entering detox.
Craving
depends on how long in treatment; will be evaluated for anti-c­raving meds if cravings do not decrease
Sleep
Poor: 2-3 hrs/night; Moderate: 5-6 hrs/night; Diffoculty staying asleep; difficulty falling asleep; drug dreams; nightmares
Appetite
Any weight fluctu­ation
Activities of Daily Living
Unkempt, slightly dishev­eled; odorous; disheveled poor hygiene
Other descri­ptors
Guarded, defensive, combative, introv­erted, social withdr­awal, med seeking, justif­ying, elevated mood, preocc­upied, passive, indiff­erent, solemn, suspic­ious, bellig­erent, abrupt, sluggish, timid, meek, people­-pl­easer, unyiel­ding, stubborn, pompous, manipu­lative, and defensive

Integrated Diagnostic Summar­y/C­linical Impression

 
legal
health
family
cravings
employment
high risk behaviors
home enviro­nment

SLAP Suicide Assessment

Specific
How specific is the plan? The more specific the details, the higher degree the present risk.
Lethal
How lethal is the proposed method? How quickly would the person die if the plan was enacted? The greater the lethality, the greater the risk.
Available
How available is the proposed method? If the tool to be used is readily available, the greater the suicide risk.
Proximity
What is the proximity of helping resources? Generally, the greater the distance the person is from helping resources, if the plan were implem­ented, the greater the degree of risk.

Assess­ments with Scoring Cutoffs

DAST (Drug Abuse Screening Test)
Scores 1-5
Low
 
Scores 6-10
Interm­ediate (likely meets DSM-V criteria)
 
Scores 11-15
Substa­ntial
 
Scores 16-20
Severe
AUDIT (Alcohol Use Disorder Identi­fic­ation Test)
Scores 0-7
Adult Ed
 
Scores 8-15
Simple Advice
 
Scores 16-19
Brief Counseling
 
Scores 20-40
Specialist
PHQ-9 (Depre­ssion)
Scores 1-4
Minimal Depression
 
Scores 5-9
Mild Depression
 
Scores 10-19
Moderate Depression
 
Scores 15-19
Moderately Severe Depression
 
Scores 20-27
Severe Depression
PCL-5 (PTSD)
Cutoff: 36
Recovery Capital
Max 175
Self-C­omp­assion Scale
Scores 1-2.5
Mild
 
Scores 2.5-3.5
Moderate
 
Scores above
High
Beck Anxiety Inventory
Scores 0-21
Mild
 
Scores 22-35
Moderate
 
Score above 35
Severe
BPS (Bio-P­s­y­ch­­o-S­­ocial w/ Integrated Diagnostic Summary)
ASAM PPC-2R (Patient Placement Criteria for the treatment of Substance Related Disorders)
Patient Placement Criteria for the treatment of Substance Related Disorders

Case Presen­tation Outline

1. Demogr­aphics & Diagnosis & Precip­itating event
Age, gender, ICD-10 Diagnosis name and code, ethnic­ity­/cu­ltural releva­nce­/sp­iri­tual, living situat­ion­/sober living­/re­sid­ent­ial­/ho­meless and Education. Precip­itating event for client seeking treatment (what made them pick up phone and come to treatm­ent). Note agencies, organi­zat­ions, or groups involved including court cases, probation, CPS, referring source...
2. Client Backgr­oun­d/R­elevant History
Previously in treatment? Age of First time to therapy or rehab. Any psychi­atric hospit­ali­zat­ions, relevant previous treatment episodes, number of times in rehab, suicide attemp­ts/­ide­ations ever in life. Share any historical inform­ation which might clarify client’s current situation, or the situation may have arisen suddenly without obvious historical causes. Signif­icant adverse or traumatic events, school perfor­mance, family structure, alcoholism or addiction in family.
3. Key findin­gs/­obs­erv­ati­ons/Ct desires
Give details of the current situation relevant to unders­tanding why this situation is a case. For example, give observable signs/­sym­ptoms of illness, enviro­nmental factors that may impinge on client, and potential resources within the situat­ion­/cl­ient. Ct desire­s/p­erc­eption of problems, Client quotes are helpful here.
4. Formul­ation
Describe your unders­tanding of why things are as they are. This should reflect one or more theore­tical perspe­ctives in some way. Note any counte­rtr­ans­ference issues.
5. Interv­entions and Plans
Treatment plan in Kipu may be refere­nced. Describe what you have done and what you plan to do about the situation. May wish to state where you on in progress on goals.
6. Reason for Presen­tation: What would you like help with?
Explain why you selected this case when you could have presented several other cases. Does it present a unique challenge or an unusual problem? Does it illustrate the effect­iveness of an interv­ention? Would you like help with the case, or are you presenting it so others can learn from your experi­ence? What do you want from us, instruct your audience.

Recovery Capital

Personal
Physical
Physical health, financial assets, health insurance, Safe and recove­ry-­con­ducive shelter, clothing, food, access to transp­ort­ation
 
Human
Identified values, personal knowledge, educat­ion­al/­voc­ational skills, problem solving capabi­lities, self-a­war­eness, self-e­steem, self-e­ffi­cacy, hopefu­lne­ss/­opt­imism, right percep­tion, sense of meaning and purpose, interp­ersonal skills
Family­/Social
Relati­onships
Partner, friend­ships, family of origin, family of choice, work, school, church, community organi­zations
 
Recovery Support
"­fam­ily­" involv­ement in therapy and/or recovery efforts, friend­s/f­amily in recovery, sober outlets for fellowship and leisurely activities
Community
 
Active efforts to reduce addict­ion­/re­covery related stigma
  
Local recovery role models
  
Availa­bility of continuum of treatment resources
  
Community recovery support instit­utions
  
Sources of sustained recovery support and early re-int­erv­ention
  
Culturally prescribed pathways of recovery that resonate with particular indivi­duals and families
 

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