The Journal of clinical psychiatry














Case Study Treatment Plan

Student Name


Mental Health Counseling Clinical Internship 1




Case Study Treatment Plan


Section 1: Identifying Information

Stella is a 38 year old orphaned biracial lady who lived with her foster parents that were Caucasian. She was adopted as an infant and has no document that may identify who her biological parents are, but recalls her conception was as a result of her then 16 year old mother being raped during a high school football game. She lives in a small city that has a population of approximately 150000 people and has worked for three years as a book-keeper at a local meat packing plant. Previously, she worked as a tax preparer for a national company. She describes her current position as enjoyable, as she is able to easily get along with numbers as compared to people. She has been married for 18 years to a man named Doug and has a 16 year old son, Tyrone, who is a junior in high school. Her son is a baseball player in the school team and a solid B student. Her husband is a long distance truck driver and is often away from home for two weeks at a time. He stays home for 3 to 4 days before leaving for another trip.

Section 2: Presenting Problem

Stella admits to feeling sad when her husband is away. Her marriage is experiencing problems due to concerns on her mental health. Despite this, the couple is committed to each other and to their marriage vows. Stella sates that her mental problems commenced in her late adolescence stages. She developed Bulimia (excessive eating) and Narcolepsy (excessive sleeping). As a result, she gained a total of 15 pounds and had a tendency to miss school. She gained access to Methamphetamines, a type of stimulant drug, from a friend at school and used them for weight loss. She lost the extra weight but found herself withdrawn anytime she didn’t use the drug and sought to get more from her friend who refused to provide the drug. Because of this, Stella’s mood became worse, and she developed an anti-social tendency towards her friends. She described her mood as ‘blue’. This occurrence lasted for at most one month, until summer break began. At this time, she improved because she got a summer job as a stocker at the local grocery store where her then boyfriend also worked.

The following year, she began feeling ‘blue’ and this time attempted suicide by taking 25 aspirin pills. She confided in her mother, who rushed her to the emergency room to have the pills pumped out. Stella was recommended to a counselor, but the sessions were brief as Stella stopped visiting immediately she felt better. She had no medication prescribed to her at the time. Three years after marrying her high school boyfriend, Stella got severe depression, worse than the previous episodes. Her suicide attempts got severe to the extent she slit her wrist in the bathroom at work. After treatment was offered, Stella began smoking Marijuana and having sex with random men when her husband was away. She also developed a drinking habit and spent money unwisely, maxing out her credit cards and borrowing money from her parents. Her work performance deteriorated and she developed a habit of stealing from her employer, eventually losing her job.

Section 3: Previous Treatments

After her last suicide attempt, Stella was hospitalized for 4 days and recommended a psychiatrist for follow-up treatment. The psychiatrist prescribed an SSRI to counter the depression and referred Stella to her previous counselor. However, Stella’s condition became worse and her Psychiatrist made adjustments to her medication regime and added a mood stabilizer.

Section 4: Strengths, Weaknesses, and Support Systems

· Stella is strong willed to fight her problem. She is also hardworking and dedicated to her family. Her main weakness is relying on drugs to keep her happy and easily going off her medication. She is also resistant when it comes to seeking help.

· Stella is dealing with addiction and depression, limiting her development in general. She has an associate’s degree which can help her develop herself and her family but her lack of self-belief is a drawback.

· Stella has a good support system from her family. Her husband changed his work schedule so that he can monitor her progress and be there for her. Her son took up the role to ensure his mother takes her medication daily. Stella’s sister in law volunteered to take therapeutic walks with her every evening. This support system, with the combined efforts of the mental health institution are proper aids to help in her recovery.

· Co-occurring substance disorder leads to recurring suicidal attempts, anxiety, paranoia and depression that may later on affect the effectiveness and productivity of an individual. This disorder can cloud judgement leading to poor decision making. It may also affect the functioning of the body, damaging vital organs like the kidney, heart, liver and lungs.

· Stella needs a change of environment, away from the triggers of her depression. As such, she may need rehabilitation, some personal space to properly focus on getting better with the help of her family and friends as positive support systems. She also needs to adopt new ways of dealing with stress. The support system is important as it emulates care and love that Stella feels she is deprived of, probably caused by the memory that she is adopted.

Section 5: Assessment

Before the assessment begins, counselors should adhere to the ethical and legal issues that enables them to make clinical judgements on their client’s circumstances. There are issues that need immediate action for example if a client refuses to sign treatment consent. Thereafter, crisis intervention is adopted. In this step, there are scenarios that may interrupt the session of treatment and require intervention. For instance cases on suicide or attempted homicide may force the counselor to redirect their focus to revert the client from performing these actions by attempting reason.

Consultation and supervision is advised for clients in an outpatient setting. The events that occur during this step may change the treatment plan and skip to referral and discharge. The next stage would be referral and discharge that is a prescription of what may seem appropriate for the client (Zimmerman et al. 2014). The counsellor should have multicultural competence knowing what language is appropriate and identify which assessments are culturally bound and how to properly administer the assessment techniques chosen. When selecting the proper DSM diagnosis for Stella, the first step would be to determine whether the disorder is malingering and factitious. The next step would be ruling out a substance etiology such as drug and substance abuse and a pre-existing condition. The next step would be deducing the specific disorder and differentiating between specified and unspecified conditions. Finally, the counselor institutes a boundary with no mental disorder with the client (Zimmerman et al. 2014).




Section 6: Diagnosis

According to the DSM-5 diagnosis, Stella suffers from depression. This is characterized by irritable moods, substance induces depressive disorder, hyperactivity disorder, adjustment disorder with depressed moods and extreme sadness. This may also be attributed by increased involvement in dangerous activities such as suicidal or homicidal thoughts (Koukopoulos & Sani, 2014). The diagnosis came as a result of Stella’s previous encounters with drugs like marijuana, stimulants and an aspirin overdose and drinking, which cloud her judgement. Her moods are also easily manipulated, in that one minute she is extremely happy and the next she is extremely sad.

She also exhibits hyper activity disorder where she feels abandoned when her husband has to work for weeks, making her opt to cheat on her husband, attempting to seek for the love she feels deprived of. Her previous suicide attempts show she is hurting mentally and is trying to seek release but in the wrong manner. The DSM-5 diagnosis uses a more dimensional approach, separating hypothetical, biological and genetic factors that may influence the type of treatment used.



Ingersoll, R. E., & Rak, C. F. (2016). Psychopharmacological for mental health professionals. An integrative approach (2nd ed). Boston, MA. Cengage Learning.


Koukopoulos, A., & Sani, G. (2014). DSM‐5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatrica Scandinavica129(1), 4-16.


Zimmerman, M., Chelminski, I., Young, D., Dalrymple, K., Walsh, E., & Rosenstein, L.

(2014). A clinically useful self-report measure of the DSM-5 anxious distress specifier for

major depressive disorder. The Journal of clinical psychiatry75(6), 601-607.



Comments from the professor for this paper.

Overall, the paper addresses the assignment tasks and clearly presents the case, the assessment and diagnosis possibilities.   In the final paper, include discussion of some specific assessments, not just the general idea for assessment. You will also want to clearly identity the specific criteria that fit to a chosen diagnosis.

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