Treatment Plan, Theoretical Intervention and Documentation
Introduction
A treatment plan is detailed with information about the progress of the being treated patient, goals, and objectives of the treatment as well as the techniques used during treatment. Some aspects are very important in a treatment plan (Schüler et al.,2017). The first aspect is problem representation, whereby the main concern of treatment is described and represented to the therapist. The next aspect is listing the goals of therapy, which are inclusive of the short- and long-term goals of therapy. Methods that are to be adopted and used during the treatment are listed and identified. To come up with a complete treatment plan, both the client and the therapists are involved in creating one (Seo et al., 2016).
In most cases, while dealing with clients, especially for the Markus case, the use of theory-based techniques is applied. It is whereby the problem is analyzed critically, and a final solution is found. A most popular theory or behavior is used to help come up with the solution(Schüler et al.,2017). As stated in the previous assignment, documentation is important in ensuring that all the progress is recorded, and anyone willing to know much more about the patient can be explained. Current symptoms of Markus are used to create a treatment plan which helps to achieve the short- and long-term goals of the treatment process.
Case identification, Conceptualization, and goals
A man by the name Markus who is 43 years of age, was the case of our study. He is a black American, heterosexual, and Christian. Further to this, he is a high school graduate who further studied management and currently working as the manager in a tire company warehouse. Markus is a decently dressed man who looks silent and depressed (Schüler et al., 2017). He has been an addict of drugs and alcohol to find solace and maybe peace.
Currently, Markus is not married, but he was previously married. He is a father of two kids who he has been taking care of them since their mother left. He succumbed to depression since his wife left him for another man. In his early 30s, he underwent gall bladder minor surgery and had an underlying condition, which is asthma(Seo et al., 2016). This condition, however, does not prevent him from performing his duties perfectly well. He has insomnia for the last two years.
Since he was divorced, Markus has been a victim of depression and turned to alcohol too. He reported that his problem began when the wife left him for another man. Due to depression, he gets easily agitated with his colleagues, kids, and friends. He said that he is anxious and unable to control his thoughts, thus overthinking. He gets afraid of the future and has not adopted the fact that he is alone, which makes him feel lonely.
The fact that he is unable to control his thinking makes him feel that he needs help. Another symptom that makes Markus think that he needs therapeutical help is due to low self-esteem, and he feels incomplete as well as not lovable (Moteabbed et al., 2016). It started immediately after his wife chose another man instead of him despite all the effort he had made in making her and the two kids feel comfortable.
During treatment, the main objective is to achieve the final best treatment solution, which is for the better to the client. It is ensuring that the client has got the desired help he or she had come to seek, and Markus’s case was no different (Seo et al., .2016). However, before achieving the final goal, there are short- and long-term goals that are set to ensure positive progress is recorded. These goals are set on the standard required. The goals must be specific, measurable, achievable, relevant, and time-based.
Short term goals
These are daily activities that take place and which can happen so quickly. For Markus, the first short term goal was ensuring that he got out of bed very early and on time will help him stay motivated and able to make the best out of the day (Moteabbed et al., 2016). Another short-term goal for Markus was ensuring that he was able to accomplish the daily schedule activity that was set for him. It was made possible by his commitment and hard work, too (Moteabbed et al., 2016). The third goal in this category was ensuring that he was able to get a healthy weight daily. It was by him going through the daily workouts together with his assigned instructor.
Long term goals
Improving and building a good relationship with Markus was one of the long-term goals in this case scenario. The good rapport created between Markus and the therapist ensured that a better trust was built, and Markus felt safe to share out his problems and the personal feeling openly. In so doing, the treatment plan was made easier and effective. Facilitating behavior change is the other identified long-term goal. In Markus’s case, ensuring that he has changed for the better is is a key point (Seo et al., 2016). The third long term goal was to ensure that Markus was able to find treatment and full recovery. It was the main objective, as well as the long-term objective.
Exploration Theory
During the treatment, Cognitive Behavioral Theory (CBT) was used. This theory focuses on challenging and changing the undesirable behavior and character and improving the emotional state of a patient. In this theory, one is shown how to deal with the current issues and not on past issues. Through CBT, Markus was taught to accept himself and helped through to improve the self-esteem, ensuring that he was able to accept himself and realize that he had no issue, nor was he worse than the man the wife chose. Instead, he was taught that it was not in his thinking that things happened that way(Schüler et al., 2017).
During the moments of therapeutic sessions, Markus worked for hand in hand with the therapist to breakdown the personal problems and the symptoms into smaller parts that helped him realize that his problems were not as big as he perceived them. After breaking them down, Markus was helped to change the negative thoughts and feelings about him and turn them to positivity (Seo et al., 2016). The therapist advised Markus to practice the changes through his daily activities. This theory finally aims at teaching one how to apply the skills and the knowledge gained. This criterion will help Markus to be in a position to manage his problems once faced with such a problem again.
Exploration of Ethical, Legal and Cultural Considerations
Ethical codes that were successfully applied include honesty, integrity, respect resilience, competence, fairness, courage, wisdom, humility and confidential, all this code worked for good to achieve the best results (moon,2019). The purpose of the ethical codes was to help control internal disagreement and protect the client from incompetent counselors, especially in the deeply personal issues (moon,2019).
While carrying out therapy sessions, there a legal issue that must be met. As a therapist, it is important to be aware of the laws regarding the activity. The first legal issue is to ensure that the therapist is trained and licensed (moon,2019). It is important to protect clients from coming across untrained and unqualified people who only call themselves therapists. Confidentiality is the legal duty of the therapist to protect the client’s private conversation. However, in cases where the client has become a threat to the therapist, it is legally accepted for him or her to break the breach of confidence for the sake of his safety(Seo et al., 2016).
During the treatment, as well as when applying the CBT theory, it is important to consider the cultural background of the client to offer the best services and treatment for the client. In the case of Markus, the therapist took the time to learn his early childhood life, whereby he stated that his father was not fully present for him while he was growing up. Other factors that were considered included his occupation and the level of his education. All these factors gave the therapist a chance to understand Markus to achieve the set goals and objectives. Markus being a black American, had a different culture from the White American (Moteabbed et al., 2016). The therapist was therefore supposed to learn about them so as not to judge Markus wrongly and help him overcome as well.
SOAP Note Documentation
Subjective data
Markus was easily agitated with the colleagues, his kids, and even friends. He felt depressed, anxious, and fearful about the future. Markus also is unable to control his thinking(Seo et al., 2016). As a man, he is lonely and unable to accept that he will spend the rest of his life alone without his wife. Further to this, he has got low self-esteem since he feels something is wrong with him since his wife left him for another man. In most cases, he has a disruptive sleep. Markus underwent minor gallbladder surgery at his young age.
Objective
He is currently in good shape and works out. However, he suffers from allergies and asthma. He reported that he constantly uses inhaler and Allegra.
Assessment
The major problem of Markus is depression. He reported that he was unable to control his thinking and even unable to sleep well. It is caused by the low self-esteem he has been suffering since his wife left him for another man(Seo et al., 2016). Ever since then, he has been unable to accept himself and the situation.
Plan
Before the next session, a plan was formulated to ensure that the goals that were set were met. The therapist made sure that before Markus had a session with him, he had completed the task given to him.
Exploration of Treatment Tasks
Self-reflection is important, especially to the therapists, as it helps create an emotional awareness (Seo et al., 2016). It is achieved by taking personal time to ask yourself personal questions, which help you gain a better understanding of what you are doing. During the treatment plan of Markus, I was able to take time as the therapist to self- reflect regarding the specified goals and the theory I used (Schüler et al., 2017).
On the goals, I was able to ask myself a lot of questions about them. I reflected on the importance of the set goals and how effective they would be for me during treatment. I asked myself whether they were timely and realistic as well as achievable, which gave me a chance to come back better and prepared. The cognitive behavior theory allowed me to reflect whether the thoughts I had on the same issues were positive or negative(Schiavi et al., 2017). Through self- a reflection on this theory created an opportunity for me to understand the important aspects of the self. They were hence becoming better in adopting the changing situations and tough times.
In ensuring that a strong connection was made between Markus and me, I was able to ensure that I maintained my focus on the client (Schiavi et al., 2017). Every statement he made, I took the time to listen to him and respond based on the topic being discussed without diverting. Additionally, by asking for clarification also allowed me to get him clear and understand him better. Clarification is important as it helps reduce the chances of assuming a statement that allows the therapist to respond correctly (Schiavi et al., 2017). Remaining confidential also was a way in which the connection between Markus and me was created due to the good rapport created.
In conclusion, the treatment plan was successful because of the theory that was used. Maintaining good ethics during the therapy process contributed a lot to the success. Without the set goals and objectives, the treatment plan would not have succeeded. The goals kept both the parties on toes in ensuring that the treatment process succeeded(Schüler et al., 2017).
References
Moon, B. L., & Nolan, E. G. (2019). Ethical issues in art therapy. Charles C Thomas Publisher.
Moteabbed, M., Yock, T. I., Depauw, N., Madden, T. M., Kooy, H. M., & Paganetti, H. (2016). Impact of spot size and beam-shaping devices on the treatment plan quality for pencil beam scanning proton therapy. International Journal of Radiation Oncology* Biology* Physics, 95(1), 190-198.
Schiavi, A., Senzacqua, M., Pioli, S., Mairani, A., Magro, G., Molinelli, S., … & Patera, V. (2017). Fred: a GPU-accelerated fast-Monte Carlo code for rapid treatment plan recalculation in ion beam therapy. Physics in Medicine & Biology, 62(18), 7482.
Schüler, E., Eriksson, K., Hynning, E., Hancock, S. L., Hiniker, S. M., Bazalova‐Carter, M., … & Maxim, P. G. (2017). Very high‐energy electron (VHEE) beams in radiation therapy; Treatment plan comparison between VHEE, VMAT, and PPBS. Medical Physics, 44(6), 2544-2555.
Seo, J. H., Kong, H. H., Im, S. J., Roh, H., Kim, D. K., Bae, H. O., & Oh, Y. R. (2016). A pilot study on the evaluation of medical student documentation: assessment of SOAP notes. Korean Journal of medical education, 28(2), 237.