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OT Treatment Plan
OTAP1316 Psychosocial Occupational Therapy
Due date: week 10
Points and Percent Grade for Assignment: 16 points/25% of
grade
Overview
The students will review the case study provided and identify
pertinent information necessary to develop a treatment plan.
The following are elements to include in the treatment plan:
● Identify client’s abilities and limitations
● Describe the impact they have on occupation
● Describe ways in which the social, political, legal, economic
and cultural environments impact client’s access to services
● List any medications and describe potential side effects that
could affect treatment
● Identify a frame of reference on which to base the treatment
approach
● Identify activities for use in treatment, based on treatment
approach
● Identify any liability issues related to the OT treatment
● Identify all precautions and safety needs
● Describe the role of the OT, OTA and other professionals
involved in this treatment approach
● Summary
Case Study: A 21-year-old woman with cocaine dependence,
polysubstance abuse, bulimia, and borderline personality
disorder
Ms. Smith is a 21-year-old woman who sought treatment after
the Department of Social Services threatened to take her two
children, a boy aged 6 and a girl aged 2. Client stated that her
neighbor reported her for leaving her children alone. Client is
unemployed and on welfare. She said she couldn't make enough
money working to pay bills and childcare. Client has drunk
alcohol and used pot since age 11. She has tried speed and
diazepam (Valium) and has used cocaine by snorting, injection,
and smoking.
Ms. Smith stated she has used crack for the past 9 months and
denies any other drugs since then except an occasional beer.
Client admitted to using her welfare check for drugs and selling
her food stamps to obtain money. She was never married and
did not receive financial support from the father of her children.
Client, who is slightly overweight, was observed purging food
in the bathroom of the detoxification unit and admitted to
episodic purging to control weight.
Ms. Smith described herself as a good student in high school
until her drug use became more important than studying. She
has a high school diploma but did not attempt college, as she
felt she could not afford it. Client’s parents both drank and were
physically abusive to one another. Ms. Smith denies physical or
sexual abuse of self or siblings by parents. Client reported she
cooks, cleans, and takes care of all household chores
independently. Ms. Smith stated she has been "out of control"
since she took up crack 9 months ago, smoking approximately
$200 worth 1 to 2 days per week at friends' homes or crack
houses. She admitted to leaving the children alone twice over
the last month and was appalled to have slept with crack dealers
to obtain drugs. Client is aware that she must get clean, or she
will lose her children. She has never obtained a driver's license
but does have a car of her mother's that she drives. She has no
friends except other users, and other than drug use, her only
leisure activity is renting a movie for the children. Ms. Smith
stated that she feels depressed much of the time and has no
energy.
OT goals identified:
1. Client will obtain a driver's license.
2. Client will identify job and educational training interests.
3. Client will identify activities to pursue with children at
home and in the community.
4. Client will improve energy level and decrease craving for
crack through exercise and proper nutrition.
Papers should be at least one pages and no longer than two
pages following the prescribed format.

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OT Treatment PlanOTAP1316 Psychosocial Occupational Therapy.docx

  • 1. OT Treatment Plan OTAP1316 Psychosocial Occupational Therapy Due date: week 10 Points and Percent Grade for Assignment: 16 points/25% of grade Overview The students will review the case study provided and identify pertinent information necessary to develop a treatment plan. The following are elements to include in the treatment plan: ● Identify client’s abilities and limitations ● Describe the impact they have on occupation ● Describe ways in which the social, political, legal, economic and cultural environments impact client’s access to services ● List any medications and describe potential side effects that could affect treatment ● Identify a frame of reference on which to base the treatment approach ● Identify activities for use in treatment, based on treatment approach ● Identify any liability issues related to the OT treatment
  • 2. ● Identify all precautions and safety needs ● Describe the role of the OT, OTA and other professionals involved in this treatment approach ● Summary Case Study: A 21-year-old woman with cocaine dependence, polysubstance abuse, bulimia, and borderline personality disorder Ms. Smith is a 21-year-old woman who sought treatment after the Department of Social Services threatened to take her two children, a boy aged 6 and a girl aged 2. Client stated that her neighbor reported her for leaving her children alone. Client is unemployed and on welfare. She said she couldn't make enough money working to pay bills and childcare. Client has drunk alcohol and used pot since age 11. She has tried speed and diazepam (Valium) and has used cocaine by snorting, injection, and smoking. Ms. Smith stated she has used crack for the past 9 months and denies any other drugs since then except an occasional beer. Client admitted to using her welfare check for drugs and selling her food stamps to obtain money. She was never married and did not receive financial support from the father of her children. Client, who is slightly overweight, was observed purging food in the bathroom of the detoxification unit and admitted to episodic purging to control weight. Ms. Smith described herself as a good student in high school until her drug use became more important than studying. She has a high school diploma but did not attempt college, as she felt she could not afford it. Client’s parents both drank and were physically abusive to one another. Ms. Smith denies physical or sexual abuse of self or siblings by parents. Client reported she
  • 3. cooks, cleans, and takes care of all household chores independently. Ms. Smith stated she has been "out of control" since she took up crack 9 months ago, smoking approximately $200 worth 1 to 2 days per week at friends' homes or crack houses. She admitted to leaving the children alone twice over the last month and was appalled to have slept with crack dealers to obtain drugs. Client is aware that she must get clean, or she will lose her children. She has never obtained a driver's license but does have a car of her mother's that she drives. She has no friends except other users, and other than drug use, her only leisure activity is renting a movie for the children. Ms. Smith stated that she feels depressed much of the time and has no energy. OT goals identified: 1. Client will obtain a driver's license. 2. Client will identify job and educational training interests. 3. Client will identify activities to pursue with children at home and in the community. 4. Client will improve energy level and decrease craving for crack through exercise and proper nutrition. Papers should be at least one pages and no longer than two pages following the prescribed format.