Regene_Best_COUN5254 Case Study Treatment Plan-2

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COUN5254 CASE STUDY TREATMENT PLAN BIOPSYCHOSOCIAL ASSESSMENT FORM Client Demographic Data Name: Hallie Age: 11 Gender: Female Race: White Ethnicity: Caucasian Religion: Non-Denominational Christian Other Relevant Information: Hallie's teacher showed concerns about her sudden change in school prompting a therapeutic intervention. The teacher noticed mood changes and weight lose. Hallie visits her father every weekend. Both parents are middle class. the father pays for child support. The father is also engaged to another woman and they are expecting a new born. Social-Cultural Information: Hallie's parents are divorced. She is Caucasian White. Her mother is drinking and staying away from home. Presenting Problem Describe in detail the reason the client is seeking counseling, including behavioral, situational, and environmental factors:

Hallie is an eleven-year-old white female in the 5th grade. She typically arrives at school very early and stays very late, spending the extra time studying for her classes. However, her mood has changed substantially at school recently, going from appearing happy and enthusiastic, to appearing depressed, tired, and uninterested. Hallie is displaying a noticeable weight loss causing teachers to be concerned. Her parents are not in good terms and this could be the reason she worries a lot and is anxious of the unknown. Her father is about to marry another woman. Hallie cries whenever asked about how she feels. Current Stressors Identify all stressors impacting the presenting problem. 1. Mother's excessive drinking 2. Loneliness since mother stays away most of the time 3. Father is engaged and getting maried soon 4. Father expecting a baby Current Symptoms Identify in detail all symptoms currently exhibited by client and how symptoms are impacting their overall functioning. 1. Hallie's social life has reduced 2. Depression 3. Tiredness 4. Disinterest in things she found interesting before 5. She typically arrives at school very early and stays very late, spending the extra time studying for her classes Family History Family members' names and ages to include parents, grandparents, and siblings: Hallie - 11 Mother - Reid - 33 Father - Ted - 38 Grandmother (mother's side) - Hilda - 60 Grandfather (mother's side) - Vin - 72 Grandmother (father's side) - Tina - 68 Grandfather (father's side) - Tim - 77 Father's Fiance - Sandra - 29 Provide a detailed narrative of the genogram you created: The Genogram indicates that all members of Hallie's family are Caucasian Whites. Hallie's grandmother (Reid's mother), Hilda is 60 years old. she has a history of alcohol use as much as this lifestyle never interfered with her marriage to Vin, Hallie's grandfather. Therefore, it is evident that Reid inherited the alcoholic lifestyle from her mother. Both Hilda and Vin became

prominent business people in real estate after leaving the military. The Genogram also shows other family members including Tina and Tim, Hallie's grandparents from the father's side who were quite responsible and needed the best for their son Ted. Tina is a retired nurse while Tim is a retired teacher. Their marriage is still intact and they live happily together. Like, Hallie both Reid and Ted were also the only children in their respective families. The Genogram also captures Ted's new relationship with Sandra, with whom they are expecting a baby. They are engaged and planning marriage soon after. Special family circumstances or events: Reid has an irregular relationship with her parents and this prevents Hallie from visiting them the same way she does to Ted's parents. Reid tends to be more absorbed to a luxurious life making her less responsible and poor relational skills. Reid is reckless and abandons her daughter every time her friends calls her for a party. Ted is is engaged to Sandra and plans to marry as soon as possible. The new couple is also expecting a baby. Current Living Situation and Environment Housing (apartment, single-family home, etc.): Reid and Hallie live together in a single-family home. Hallie's father lives some distance away but within the same district. Who is living in current household? (Parents, grandparents, siblings, etc.): Hallie and her mother Household Stressors impacting client (financial, space issues, safety concerns): Hallie is worried about her safety because her mother stays away most of the time. Reid spends more an alcohol influencing financial constraints. Family History of Mental/Psychological Issues Identify and describe each family member who has experienced mental health issues, current and past, diagnosed and undiagnosed (refer to genogram): Hilda suffered Alcohol Use Disorder. Reid, Hallie's mother is also showing symptoms of alcohol dependence. Client Personal History Major Life Events: Hallie was born in March, 2010. She started her early childhood education at a local school in 2016. Her parents divorced in 2021 after a relationship full of tension and fights. She is currently in her 5th Grade and has been doing well until the stressors cropped in. History of Trauma and/or abuse: No abuse. According to the case, the parent's divorce influenced by Hallie mother's drinking habits, is the

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main cause of trauma Physical/Medical Information Developmental history (birth issues, developmental milestones, etc.): Hallie met all developmental milestones from pregnancy, as a new born baby and toddler Physical/medical history: Hallie underwent all immunizations. She also goes for regular health checkups every year using her father's health insurance. No physical or medical history is accustomed to her past life. Current physical/medical state: Hallie is currently underweight following a stressful environment she is living currently She is also showing the symptoms of depression and anxiety. Current Medications (prescribed or OTC): None Other medical issues (allergies, etc.): Occasional use of over-the-counter benadryl medicine to combat seasonal allergies. Previous Mental Health History/Treatment Previous Mental Health History/Treatment (include in-patient, out-patient, residential, in-home, etc.): None Substance Abuse/Addiction History and Current Situation Substance Abuse/Addiction History and Current Situation (include client and client's family members): Hallie uses no substances. However, her mother and grandmother have alcohol dependence history. Ecomap Analysis Analyze the relationships between community systems, family systems, and school systems that could support the client through treatment, counseling and beyond: Hallie's close relationships includes her mother, father, the teachers, the school fraternity and other members f the community which are not widely pronounced. The teachers are strongly mentioned as they show concern creating a direct care relationship for a struggling Hallie. Her father is also close to her and provides the main emotional support framework. Safety

concerns lies with her mother who stays with her and feeds her as much as Reid is consumed by alcohol use. Her grandparents from the father's side also bring in emotional support for Haille. Legal and Ethical Considerations Legal and Ethical Considerations: The main legal and ethical consideration in Hallie's case is lack of informed consent hence the need to incorporate the parents throughout therapy TREATMENT PLAN Presenting Problem Client presents with: Primary Diagnosis: 311 (F32.9) Unspecified Depressive Disorder Other Factors: V61.20 (Z62.820) Parent-Child Relational Problems V61.03 (Z63.5) Disruption of Family by Separation or Divorce 995.52 (T76.02XA) Child Neglect Suspected As evidenced by: 1. Hallie's social life has reduced 2. Significant weight loss 3. Depression 4. Tiredness 5. Disinterest in things she found interesting before 6. She typically arrives at school very early and stays very late, spending the extra time studying for her classes Due to: The main stressors in Hallie's situation include: 1. Mother's excessive drinking 2. Loneliness since mother stays away most of the time 3. Father is engaged and getting married soon 4. Father expecting another baby Theoretical Foundation Choose two counseling theories and compare and contrast the application of these theories to the client's treatment. Psychodynamic theory and Cognitive Behavioral Therapy will be used in HallieâÂ€Â™s case. According to Colarusso and Nemiroff (2013), Psychodynamic theory is a counseling approach

that focuses on understanding early life experiences and how those experiences affect current personalities and behaviors. This approach will be effective in averting HallieâÂ€Â™s problems because it enhances the client's and close associates such as parents' understanding of what influences, motivates, and affects their behaviors, thoughts, and feelings as stipulated by Colarusso and Nemiroff (2013). Creating more awareness is imperative because it helps to divert the client's attention to their conscious self. On the other hand, Cognitive Behavioral Therapy will be ideal for improving HallieâÂ€Â™s thoughts and behavior by replacing them with new, relearned adaptive behaviors or skills to enhance functioning as stipulated by DuBois et al. (2017). CBT will effectively explore the impact created by each stressor such as her motherâÂ€Â™s excessive drinking and find a way to restructure the broken trust between Hallie, her mother, and other close associates. Both the psychodynamic approach and CBT will be ideal while working with Hallie. This analogy affirms their effectiveness. However, CBT focuses on the current cognitions and actions that reflect a change from the usual. In this case, the counselor works to restructure such anomalies without digging deeper into earlier life experiences (DuBois et al., 2017). On the other hand, psychodynamics focuses more on the clientâÂ€Â™s early life experiences and how it is affecting the behaviors now (Colarusso & Nemiroff, 2013). Therefore, a combination of the two theoretical frameworks in HallieâÂ€Â™s therapy will be imperative because they complement each other in generating a better outcome as far as HallieâÂ€Â™s problems are concerned. Haynes et al. (2020) emphasize evaluating the association between a parentâÂ€Â™s exposure to Adverse Childhood Experiences (ACEs) and outcomes of depression and anxiety among their children by indicating that both current and vast experiences influence the mental health of children and adolescents. Therefore, starting therapy by assessing the current behavior through CBT with the consequent incorporation of the psychodynamic approach to evaluate the origin of the stressors will bolster the treatment plan in the long run. Long Term Goals Develop a minimum of 2 appropriate long-term goals for the client. 1. Hallie will learn coping measures to reduce the symptoms of depression such as loss of appetite, loss of interest, sadness, seclusion, and loneliness 2. Hallie will form a positive connection with her mother to enhance Parent-Child Relationship Short Term Goals Develop a minimum of 2 short-term goals for each identified long-term goal (a total of 4 or more). Long Term Goal 1: (a) Hallie will enroll and participate in counseling sessions to impart her coping skills to reduce depression Symptoms. (b) Hallie will participate in group-organized events to learn social skills that will bolster her interactions with peers and teachers Long Term Goal 2: (a) Hallie will spend more time with her mother to bolster her mindfulness. (b) HallieâÂ€Â™s mother will be incorporated into the treatment plan to reduce her alcoholism. Interventions

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Develop two individual counseling interventions. A minimum of one of these interventions should be grounded in play therapy. Child-Centered Play Therapy (CCPT) will be perfect for Hallie as she begins a lasting treatment plan. According to Kress et al. (2019), CCPT allows the counselor to let the child lead most of the interactions because the intervention is based on a humanistic approach that utilizes empathy, congruence, and unconditional positive regard within therapy to create a collaborative atmosphere for a speedy recovery. Hallie will benefit from this therapy because she will have a sense of control over her situation making her own her problems and allowing her to explore her thoughts and feelings as required in both the psychodynamic approach and CBT dynamics. Additionally, incorporating free association intervention used in psychodynamic platforms improves the interpretation of oneself. The counselor will be placed in a better position to evaluate and understand HallieâÂ€Â™s vast experiences including dreams and other traumatic exposures that might influence the current situation as stipulated by Colarusso Nemiroff (2013). Psychoanalysis allows therapists to help their clients to gain insight into how their past experiences inform their present behavior. Develop two family counseling interventions. A minimum of one of these interventions should be grounded in play therapy. While focusing on the family structure and the immediate problems, Reinforcement of positive health behaviors is imperative in HallieâÂ€Â™s situation. According to the mentioned analogy the counselor, through the teachers or the parents can uphold rewarding strategies to bolster the little positive change shown by Hallie. By considering the dynamics of CBT, this intervention helps appreciate the strengths of a client for continuity as stipulated by Sorek (2019). Secondly, Filial Play Therapy helps in building relationships faster between parents and their children. It upholds empathy, congruence, and unconditional positive regard needed to mend the broken bridges in families (Hu, 2021). This intervention will provide a new platform for Hallie to build a warm relationship with her mother. Improving the parent-child relationship will bolster the treatment of depression in HallieâÂ€Â™s case. The one-on-one child-centered play sessions will ensure the relationship improves consistently. Develop two group counseling interventions. A minimum of one of these interventions should be grounded in play therapy. Exposure therapy will be ideal for Hallie in a group setting following her reduced self-esteem, poor social skills, and seclusion which has greatly reduced his interpersonal skills. Putting Hallie in groups of peers and assigning them joint tasks will improve her social skills as she gains significant collaborative skills that will help her embrace others as stipulated by DuBois et al. (2017). The best play therapy in a group setting is Cognitive Behavioral Play Therapy (CBPT) with a major focus on modeling. The counselor uses CBT techniques to create a conducive environment for all group participants before acting as an example in creating change within the group formed (Kress et al., 2019). Hallie will learn and adapt to various changes based on the counselor's and peersâÂ€Â™ performances Community Resources and Social Supports Identify and evaluate the community resources and social supports in your home

community that are available for this client. Also, identify the strengths and limitations of the supports and resources. Various resources and social support are available to aid in solving HallieâÂ€Â™s problem. The resources at HallieâÂ€Â™s disposal are adequate and would provide a formidable foundation to start and complete a desirable treatment plan. The resources together with the various experts provide a child-friendly environment for quick recovery from the psychological trauma caused by divorce and alcoholism that compounded HallieâÂ€Â™s depressive symptoms. Various community resources and social supports are listed below. 1. Alcoholics Anonymous (AA) will be an imperative consideration for HallieâÂ€Â™s mother to reduce or stop drinking because it is the major stressor behind the divorce, child neglect, and the poor relationship with her daughter. 2. Mental health counseling facilities such as local agencies and private practitioners help in providing therapeutic interventions to avert HallieâÂ€Â™s problems. 3. Recreational facilities such as social halls, playing grounds, and parks provide platforms to actualize most of the play therapy techniques. 4. Urban Ministries Safe House and the Domestic Violence Victim Assistant Program provide information and guidance for children in similar situations as Hallie (Data Portal, 2022). This social support system provides significant after-school care to bolster the counseling programs championed by mental health experts. Legal, Ethical and Other Considerations (Including Diversity) Identify a minimum of three current or potential legal issues that may impact the client's case. 1. The first ethical concern is informed consent before Hallie is engaged in any therapy. As a child, she lacks the capacity to grant consent for any therapeutic involvement. The strained relationship between the parents may affect the consenting process especially where both parents are needed. Section E.13.b. of the ACA (2014) code of ethics. 2. Secondly, confidentiality concerns may arise. The parents are not together hence may not be ready to share information freely to help in achieving Hallie's therapeutic goals. Section B.5.c of the ACA (2014) code of ethics emphasize the procedure for releasing confidential information. 3. Lastly, the counselor may opt for a group therapy since Hallie's social skills are also diminished. In that case, another ethical consideration would be B.4.a. Group Work dynamics. Identify a minimum of three current or potential ethical issues that may impact the client's case. 1. As a legal concern, child neglect may arise during therapy because as it stands, Hallie is affected by her mothers detached behavior and alcoholism. Reid rarely stays around at home to provide support to Hallie. 2. The second legal concern when counseling minors is the possibility of terminating the counseling relationship before therapeutic goals are achieved. This may occur because of the irregular relationship between the parents hence a need to be keen throughout. 3. Lastly, just by informing the parents about the therapeutic engagements, the counselor is obeying both federal and state law that protects minors. Client Case Annotated Bibliography

Haynes, E., Crouch, E., Probst, J., Radcliff, E., Bennett, K., & Glover, S. (2020). Exploring the association between a parentâÂ€Â™s exposure to Adverse Childhood Experiences (ACEs) and outcomes of depression and anxiety among their children. Children and youth services review, 113, 105013. The study explores the association between a parentâÂ€Â™s exposure to Adverse Childhood Experiences (ACEs) and outcomes of depression and anxiety among their children. According to the authors, traumatic experiences are associated with parenting behaviors later in life hence the need to understand and address the intergenerational nature and consequences of ACEs. I will use this article to dig deep into HallieâÂ€Â™s life as a victim of separation. Hu, F. H. (2021). High-Conflict Divorce: Therapeutic Approaches for Children This study addresses the impact created by divorce, especially on children. The authors highlighted that high-struggle separation has a wide scope of negative implications for youngsters including elevated degrees of tension and discouragement. I will use this article to create more informative insights while dealing with HallieâÂ€Â™s case. Kim, S. G., Weissman, D. G., Sheridan, M. A., & McLaughlin, K. A. (2023). Child abuse and automatic emotion regulation in children and adolescents. Development and Psychopathology, 35(1), 157-167. This article focuses on the problems children and adolescents encounter that amount to abuse and emotional disturbance. The authors, Kim, Weissman, Sheridan, and McLaughlin suggest that child abuse is associated with an elevated risk for psychopathology. The findings established childhood emotional and physical abuse, in particular, may influence automatic forms of emotion regulation. This article will provide a guiding structure for the interventions of HallieâÂ€Â™s problems. McLaughlin, K. A., & Lambert, H. K. (2017). Child trauma exposure and Psychopathology: Mechanisms of risk and resilience. Current opinion in psychology, 14, 29-34. This article highlights the essentials of child trauma exposure and psychopathology by focusing on mechanisms of risks and resilience. Four mechanisms are discussed including information processing biases that facilitate rapid identification of environmental threats. I will use the content of the study to map out the problems presented by Hallie during evaluation and diagnosis. Sorek, Y. (2019). Children of divorce evaluate their quality of life: The moderating effect of psychological processes. Children and Youth Services Review, 107, 104533. This article provides insights into the quality-of-life children who face divorce problems have as adults. The author attempts to analyze hazard and strength factors connected with the self- announced personal satisfaction of offspring separated from guardians, with specific accentuation on mental cycles: self-fault for the separation and parental clash and dynamically adapting to it. This article will help me to design the best therapeutic interventions. Treatment Plan Academic Resources American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Colarusso, C. A., & Nemiroff, R. A. (2013). Adult development: A new dimension in psychodynamic theory and practice. Springer Science & Business Media. Data Portal. (2022, February 3). Data. https://www.vdh.virginia.gov/data/ DuBois, R. H., Rodgers, R. F., Franko, D. L., Eddy, K. T., & Thomas, J. J. (2017). A network analysis investigation of the cognitive-behavioral theory of eating disorders. Behaviour Research and Therapy, 97, 213-221.

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Haynes, E., Crouch, E., Probst, J., Radcliff, E., Bennett, K., & Glover, S. (2020). Exploring the association between a parentÃ¢ÃÂ‚âÂ‚¬ÃÂ‚âÂ„¢s exposure to Adverse Childhood Experiences (ACEs) and outcomes of depression and anxiety among their children. Children and youth services review, 113, 105013. Hu, F. H. (2021). High-Conflict Divorce: Therapeutic Approaches for Children Kim, S. G., Weissman, D. G., Sheridan, M. A., & McLaughlin, K. A. (2023). Child abuse and automatic emotion regulation in children and adolescents. Development and Psychopathology, 35(1), 157-167. Kress, V. E., Paylo, M. J., & Stargell, N. (2019). Counseling children and adolescents. Pearson Education. McLaughlin, K. A., & Lambert, H. K. (2017). Child trauma exposure and Psychopathology: Mechanisms of risk and resilience. Current opinion in psychology, 14, 29-34. Sorek, Y. (2019). Children of divorce evaluate their quality of life: The moderating effect of psychological processes. Children and Youth Services Review, 107, 104533. Case Conceptualization Hallie is an eleven-year-old white female in the 5th grade. She typically arrives at school very early and stays very late, spending the extra time studying for her classes. Her mood has changed substantially at school recently, going from appearing happy and enthusiastic, to appearing depressed, tired, and uninterested. Hallie is displaying a noticeable weight loss causing teachers to be concerned. When a teacher asked Hallie how things were going she began to cry and said that her mother was drinking and staying away from home a lot. Hallie visits her dad every other weekend. He has recently become engaged to be married to a woman and they are expecting a baby. According to Kim et al. (2023), children are weak to any form of abuse including the aftermath of domestic violence that results from divorce. According to American Psychiatric Association (2013), Hallie falls within the diagnostic criteria for 311 (F32.9) Unspecified Depressive Disorder per the symptoms she presents such as noticeable weight loss, feeling uninterested in things she liked before, low appetite, withdrawal from social platforms, and sadness. She is also experiencing V61.20 (Z62.820) Parent-Child Relational Problems, V61.03 (Z63.5) Disruption of Family by Separation or Divorce 995.52 (T76.02XA), and Child Neglect Suspected as stipulated by the American Psychiatric Association (2013). The counselor would incorporate a psychodynamic approach to understanding HallieâÂ€Â™s early experiences before the eventual trauma caused by her motherâÂ€Â alcoholism, divorce, and the fact that her dad is expecting another baby with another woman whom he intends to marry. According to Colarusso and Nemiroff (2013), the psychodynamic theory emphasizes early relationships as well as the quality of caregiver attachments. Additionally, integrating the aspects of CBT makes it easy to understand HallieâÂ€Â™s current behavioral change and the main stressors attached to them. In this case, the counselor will focus on the immediate cognitive and behavioral changes that need restructuring and reframing for her to regain her self-worth. More importantly, both theoretical milestones aim to explore the client's stressors and behavioral change before creating the therapeutic insights required to avert HallieâÂ€Â™s condition. For the best outcomes and a more comprehensive treatment plan, play therapy will take a central role in HallieâÂ€Â™s case. According to Kim et al. (2023), play therapy boosts emotional regulation before the main therapy is actualized. The counselor will, therefore, consider Child- Centered Play Therapy (CCPT) for the individual counseling level, Cognitive Behavioral Play Therapy (CBPT) for group interventions, and Filial Play Therapy at the family level where

parental impact is needed. On the other hand, other interventions that will bolster play therapy include exposure therapy which focuses on creating a new dimension of thinking and behavior. Additionally, Reinforcement of positive health behaviors w

Regene_Best_COUN5254 Case Study Treatment Plan-2

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