Treatment Plan

.docx

School

Capella University *

*We aren’t endorsed by this school

Course

5013

Subject

Health Science

Date

Feb 20, 2024

Type

docx

Pages

Uploaded by Munchichi13

Treatment Plan Jessica M Watts Capella University SWK 5013 Dr. Jennifer Agelidis 06/04/2023

Case History Identifying Information : Olivia Pepper is an African American Woman, age 30 years old. She is petite with brown eyes and medium-length brown hair. She is wearing baggy clothes and appears to be unkempt. Her behavior seems to be on edge and nervous. Referral Source : Olivia was referred to the University Counseling Center by her professor. Her referral was due to concern over her behavior and an overall decline in academic performance. Presenting Problem : Olivia's professor referred her due to her erratic behavior, spotty attendance in class, and tardiness. Olivia is described as a "bright student" by her professor but is failing two classes. Olivia's peers have reported she has a disinterest in her coursework assignments and has "smelled of alcohol" on more than one occasion. Olivia states she "has no desire to get out of bed." She shares that these feelings have increased over the past six months and says she feels "worthless." She has no support system as she hasn't communicated with her mother since she was 14, her father passed away, and she does not talk to her sister. Olivia's husband does not understand her mental health struggles and will yell at her to get out of bed. He is not a support for Olivia. Olivia is concerned about her children and how her mental health impacts their development. Olivia has a concern regarding turning into her mother. History of Problem : Olivia's erratic behavior has been seen since she was about 14 years old. Around this age is when her mother left, and her father became the sole parent in the household. Olivia began drinking alcohol around the time her mother left. She got her first DUI at 16 years old. This was when she first received treatment at a facility, but she states, "she did not have an issue drinking." Olivia started drinking again after the birth of her first child. She says, "her baby had colic and her coping mechanism was drinking." She got her second DUI

when she was 22. Olivia lost her job because of the second DUI. After the birth of her second child, Olivia states, "it all became too much," and she attempted suicide by overdose and alcohol consumption. Due to this attempt, Olivia was hospitalized and decided to seek treatment with AA to help her get better. Olivia finds that church and AA are essential to her life and have motivated her to return to school to help children like herself, and everything seems to be going fine. Olivia admitted that she started drinking again throughout the school day and would sneak drinks at home so her family wouldn't see. Olivia feels pressured to leave school because her husband recently got laid off from work, and he wants her to work to help with bills until he can find a job. Olivia feels overwhelmed by her situation at home, affecting her academic performance. Olivia's stressful situation is also contributing to a mental health decline. Olivia presents to my office in baggy, loose-fitting clothes. Her hair is messy but pulled back. She comes off defensive and appears to be anxious. Olivia seemed distracted and was constantly fidgeting and biting her nails. Her thought process appeared disorganized, and she needed help to stay on topic. There seems to be some denial and avoidance surrounding alcohol use. Olivia harbors guilt about her drinking, parenting, academic performance, and who she is becoming. She has considerable depression that can be seen physically in her appearance. Her anxiety is present in her mannerisms. Olivia feels her family is financially vulnerable, and she does not know how she will help and continue her education. Olivia is feeling overwhelmed in all aspects of her life currently. Throughout the session, Olivia avoided and excused talking about her alcohol use. More discussion will be had regarding her enrollment with the University. Depending on what Olivia decides, a conference will be held with the school's dean and school board to help her academically proceed with the following steps. With continued enrollment, Olivia will be

encouraged and supported to reach out to the University's Disability Services to obtain accommodation for her classes that may alleviate some of her feelings of being overwhelmed. Previous Counseling Experience : Family Counseling in her teens. Individual counseling after hospitalization. Family Background : Mother, Mrs. Gloria Louis, age 49. Gloria grew up in a religious household where they attended church every Wednesday night for bible study and every Sunday for mass. Gloria was the oldest of 5 siblings. Her dad ran a construction business, and her mother stayed home with the kids. They lived comfortably. Gloria started exhibiting symptoms of severe depression when she was 13. By the time she was 15, she was experiencing frequent highs and lows in mood, negatively impacting her decision-making. She started stealing money from her parents and running away to spend nights with her boyfriends. Gloria's parents feared for her safety and future and decided to put her in an all-girls boarding school. She was prescribed lithium, doxepin, and diazepam. She was officially diagnosed with bipolar disorder, major depressive disorder, anxiety, and PTSD. Gloria did not maintain a relationship with her family once she aged out of the group home (at 18). Gloria met Tony at a bar in a small town, and they fell in love quickly. They had only dated for three months before they got married. At 19 years old, Gloria gave birth to her first child Erin (Olivia's older sister). When Gloria was 24 years old, she had Olivia. Olivia was a quiet baby, easy to take care of. However, Gloria suffered from severe postpartum depression and required hospitalization. When Olivia was two, her mother relied on help from her father often. Gloria had a habit of starting and stopping her medications frequently, which consistently altered her mood and behavior. Gloria was not a present parent during Olivia's childhood. She was either out for days at a time or home sleeping. By the time

Olivia was in her teens, Gloria had left and did not return. Olivia has not talked to her since by choice. Father, Mr. Tony Louis, died at 54 from liver cirrhosis directly related to alcoholism. Tony grew up in an abusive household at the hands of his alcoholic father. They lived in poverty and never knew where their next meal would come from. Tony started acting out in his early teenage years. He was 12 when he started drinking. His drinking continued to worsen, and he frequented the bars daily. Tony met his wife, Gloria, at one of his regular spots. Tony had two children, Erin and Olivia. Tony and Gloria had a difficult marriage between Gloria not maintaining stability on her medication and Tony's continued drinking. Eventually, Gloria left, and Tony became a single father. His drinking never stopped. Husband, James Pepper, 32 years old. Oliva and James were high school sweethearts and married when she turned 18. They have three children together. Olivia and James frequently argue about her drinking and his struggle with keeping a steady job. James recently lost his position in his current career. He pressures Olivia to step up to help but is unsupportive regarding her mental health struggle. James does not know how bad it's been for Olivia recently, and she hides her drinking from him. Olivia has three children, aged 2, 6, and 8. We did not discuss her children in detail at this time. Personal History : Olivia was born to Gloria and Tony Louis with no birth complications. Olivia was a quiet baby, easy to care for. She met all her developmental milestones throughout childhood. When she was around six, she noticed her mother would leave for long periods without communication. Olivia often sat on her front porch and waited to see if her mother would come home. Eventually, this became so common that Olivia stopped waiting

around. Olivia's relationship with her father was strong, and they spent much time together. Olivia was a good student and performed proficiently for the grade level. When she was 14 years old, her mother left, and that's when Olivia's academic performance started to decline. Olivia would often skip school to go drinking with her friends. Olivia's father struggled with his drinking problem while trying to figure out how to be a single father. At 16, Olivia got her first DUI and stayed at a center for drinking. Her dad thought it to be the best option. Throughout her adulthood, Olivia often turns back to drinking when things get hard to deal with. She earned her second DUI when she was 22 years old. Medical History : Olivia's overall health has been good. She goes to yearly physicals. However, Olivia struggles with mental health and has done a stay in the hospital for a suicide attempt. Olivia was referred to a treatment program and individual therapy. Educational History : Olivia completed her GED. She is currently at university, and her academic performance is in decline. Social Class : Olivia's family is considered working class. Cultural History : Olivia is an African American woman. Both of her parents are African American. She was born and raised in the South. Olivia married a Caucasian man, and they have three children. Spirituality : Olivia grew up Baptist. Currently practices no religion. Mental Status/Current Functioning : Appearance : Olivia is dressed in baggy clothing, her hair unkempt and overall messy. Attitude : Olivia is not aggressive or belligerent. She is cooperative throughout the interview. Motor activity : Olivia has no tremors, tics, or muscle spasms. She appears to be discouraged. Affect : Olivia's tone is appropriate for conversation.

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