Treatment Plan

Patient Details Provider detailsName: Lilly SamuelsName: Neil Duchac, PhD., LPCC-SGender: FemaleEvaluation Date: 1-4-2009Date of Birth: 3-12-1970Plan Date: 15-2-2010Race: Caucasian Employment Status: currently joblessTreatment Plan

Identifying Information

Client Name: Lilly Samuels

Gender: Female Date of Birth: 12 December 1980 Race: Caucasian

Address:

Evaluation Date: 1 April 2008 Plan Date: 25 September 2010

Employment: Currently unemployed

Presenting the Problem

Samuels is a forty one year old Caucasian woman in an abusive relationship. She is committed to this relationship having been married for more than ten years, and she will do whatever she can to save it. She is a married woman who has a strong religious background and she does not believe in divorce and separation. Her family is far away and she has few friends. In addition to this, she lives with her husband alone since they have not been able to have any children. She does not like disclosing matters of her private life to people since her husband is a well-known public figure. To deal with her abusive relationship, she started taking alcohol early on in her marriage. She indicates that she started taking a glass of wine in the morning; right after her husband went to work after abusing her. This progressed to a whole bottle of wine in the cause of the day and she is currently in a situation where she cannot control her drinking. She has never visited any rehabilitation center and the only one she has confided in is her psychiatrist. Samuels is not in formal employment. She participates in charities, fund raising events and other social work whenever she can. Samuels says that she is ready to change her life and she is willing to start treatment.

Diagnosis

Axis 1: 305.90 Alcohol Dependence

Axis II: 301.9 Personality disorder not otherwise specified

Axis III: Defer to medical

Axis IV: Unemployment

Axis V: GAF 65

Assessment

Samuels underwent a CAGE assessment test when she came to the clinic. She answered yes to three questions. She felt that she should cut down her alcohol consumption and she was feeling guilty about it. She also noted that she had a drink first thing in the morning to steady her nerves, and get rid of a hangover. She answered that she was not annoyed by people criticizing her drinking. This is probably because she hid it so well from the other people and did not socialize much. Samuels also undertook an AUDIT assessment. She noted that she took ten or more glasses containing alcohol in day and that four or more times a week, she found out that she could not control her drinking once she had started. She failed to do what was expected of her three or more times a week and that she had needed to drink first thing in the morning four or more times in a week. Samuels indicated that she had never failed to remember what had happened the previous night and that she had never been injured because of drinking. She noted that no relative or friend had ever been concerned about her drinking or told her to cut down.

Previous Treatment Successes and Failures

This was Samuels’s first attempt to get treatment after her psychiatrist recommended it. She had never sought any treatment before and there was therefore no way of determining whether the treatments would fail or they would be successful.

Strengths/Weaknesses and Social Support Systems

Samuels know the cause of her problems and she is ready and willing to change her life. This means that she will have to take drastic measures and compromise on some of her beliefs and principles. Admitting that she has a problem is her first step towards recovery. The next step is moving away from the abusive relationship and relocating to a place where she will find the much-needed support that she will require towards recovery. Her parents are still alive and well, she also has two brothers, and a sister who she knows would be willing to support her. She indicates that she is a strong-willed woman, who completes what she has started and does not quit easily.

Lilly revealed that her major weakness was lack of trust in others, which made her alienate herself from her friends and others who are close to her. She admits that her major problem has been not opening up to anyone close to her and not seeking help when she first realized that she had a problem. Alienating herself from the others meant that she had no one to share her problems with and she carried the problems alone. Her husband’s violent behavior towards her has caused her to experience instances of depression though she mentions that this is not a common occurrence. She gets relief when she participates in charities and other social work and this makes her to forget her problems for a while.

Long Term Goal

Samuels’s long-term goal is to redefine herself as a woman. She wants to stop her drinking and have a new beginning in life. She wants to find a meaningful job, which will earn her a salary and enable her to sustain herself. She reveals that she does not rule out the possibility of loving again and she hopes to be in a loving relationship one day

Short Term Goals and Objectives

  1. Lilly will see a physician to determine the extent of the physical injuries caused by her husband
  2. She will move out of the abusive relationship that she is in within three weeks to start treatment and seek shelter elsewhere
  3. She will attend counseling once a week for eight weeks so that she can heal psychologically and reestablish her emotional stability
  4. She will continue doing social work with the various groups for at least three months
  5. She will start attending a social support group for four months, for women who have been abused and have been violated by their husbands, especially those who are considered powerful.
  6. Samuels will start attending at least two open session of AA daily for eight weeks
  1. She will comply with alcohol screening on a daily basis for two weeks and is she shows any progress, the screening will be done twice a week for the next four weeks.

Timeline

The short-term goals will be evaluated for the specified period. Some of them will only take one day while others will last for more than three months

Aftercare

Lilly has to continue with the counseling sessions with her therapist, after the short-term goals and objectives have been reached. She will do this once a month for at least one year. She will continue attending AA sessions for six months to make sure that she is cured. Since she started fund raising and working with charities, she will continue doing this until she gets formal employment.

Relapse Plan

Lilly is careful not to rule anything out and she realizes that she might relapse during and after the course of her treatment since she has been dependent on alcohol for quite a long time. In case this happens, she will immediately contact the counselor, who will then direct her on the next step to take

Signature

 

I have read the above program and I am ready and willing to participate in the above program. I fully understand that this program will be re-evaluated after the indicated time and I have a right to be present at this meeting.

Progress Note

Date: 12 October 2010

Duration: One hour

Summary

I met with Lilly today for one hour. Though it has only been less than one month since the treatment began, Lilly has shown improvement in her drinking habits. As she indicated, she no longer drinks in the morning and she is starting to control her drinking. Within such a short period, she has shown tremendous improvement. She separated from her husband after the treatment began and moved to live with her parents for a while. The Physical injuries she had sustained while she was still living with her husband are healed and her emotional health is improving. She however continues to suffer because of the violent abuse she suffered and she has bad dreams about it. She continues doing social work and she is considering employment in that field. I noticed the confidence and I noticed that she smiled for the first time since I met her. Her progress is encouraging though there is still a lot of work to be done.

 

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