Running head: SMITH TREATMENT PLAN 1 SMITH TREATMENT PLAN 2 Case History Treatment Plan: Sally Smith Student School Case History for Treatment Plan Report Regarding Sally Smith Name: Sally Smith SS#: 000-00-0000 Age: 42 years old Date of Examination: 9/1/2016 Examiners: Fred Looney, PhD Chief Complaint: Mental functioning Sources of Information Clinical Interview with Sally Smith Medical Records Brief Mental Status Examination Wechsler Adult Intelligence Scale-IV (WAIS-IV) Background Information Ms. Smith is a 42-year-old African American female. She currently lives with her mother. She states she has one adult son from a prior marriage. Ms. Smith states she has a 2-year nursing degree and was employed as a nurse until 2015. She indicates that she does not attend church currently, but her mother attends on a weekly basis. As a child, she attended Sunday school and church periodically. Ms. Smith states that she has been unable to work as a nurse due to medical problems. She reported that for years she had problems with high blood pressure, and, one day, she passed out and was put on a respirator. With further questioning, she reports that, on the day of this hospitalization, she drank an alcoholic beverage that reportedly was laced with “some drug.” Her medical records show a positive drug screen of benzodiazepines. The medical records state she was “brought in a comatose state” and was intubated. The doctor’s records state that Ms. Smith had told him she had been taking OxyContin for pain and had gone to lunch with friends and had two drinks. When asked about the information in the medical records, Ms. Smith admitted to some problematic drinking during a one-year time frame. However, her reported history and the medical records do not coincide. Medical records report a diagnosis of alcohol poisoning. Her medical history includes inflammatory bowel disease, acute gastritis, atypical chest pain, hypertension, and a history of alcohol abuse with elevated alcohol levels during admission. Ms. Smith states she has a history of depression and was admitted to a state hospital in 2016 due to suicidal ideations. She states her abusive alcoholic drinking is related to her depression. She does admit to consuming a “small” bottle of vodka on a daily basis at the height of her drinking. She denies any current alcohol use and is reportedly under the care of a doctor. She states her current diagnosis is bipolar disorder. She reports that she hears voices in her head and, at times, verbally responds to them. Ms. Smith was not able to list the medications she is currently on, nor are there any recent medical records as to her current medical conditions. Most recent record is January 2016.Mental Status and Behavioral Observations Attitude and Behavior: Ms. Smith was friendly and cooperative throughout the interview. She appeared to respond in a genuine manner when asked questions. At times, however, she appeared to be confused with the in ...

1. Running head: SMITH TREATMENT PLAN
1
SMITH TREATMENT PLAN
2
Case History Treatment Plan:
Sally Smith
Student
School
Case History for Treatment Plan
Report Regarding Sally Smith
Name: Sally Smith
SS#: 000-00-0000
Age: 42 years old

2. Date of Examination: 9/1/2016
Examiners: Fred Looney, PhD
Chief Complaint: Mental functioning
Sources of Information
Clinical Interview with Sally Smith
Medical Records
Brief Mental Status Examination
Wechsler Adult Intelligence Scale-IV (WAIS-IV)
Background Information
Ms. Smith is a 42-year-old African American female. She
currently lives with her mother. She states she has one adult son
from a prior marriage. Ms. Smith states she has a 2-year nursing
degree and was employed as a nurse until 2015. She indicates
that she does not attend church currently, but her mother attends
on a weekly basis. As a child, she attended Sunday school and
church periodically.
Ms. Smith states that she has been unable to work as a nurse
due to medical problems. She reported that for years she had
problems with high blood pressure, and, one day, she passed out
and was put on a respirator. With further questioning, she
reports that, on the day of this hospitalization, she drank an
alcoholic beverage that reportedly was laced with “some drug.”
Her medical records show a positive drug screen of
benzodiazepines. The medical records state she was “brought in
a comatose state” and was intubated.
The doctor’s records state that Ms. Smith had told him she had
been taking OxyContin for pain and had gone to lunch with
friends and had two drinks. When asked about the information
in the medical records, Ms. Smith admitted to some problematic
drinking during a one-year time frame. However, her reported
history and the medical records do not coincide. Medical
records report a diagnosis of alcohol poisoning.
Her medical history includes inflammatory bowel disease, acute
gastritis, atypical chest pain, hypertension, and a history of

3. alcohol abuse with elevated alcohol levels during admission.
Ms. Smith states she has a history of depression and was
admitted to a state hospital in 2016 due to suicidal ideations.
She states her abusive alcoholic drinking is related to her
depression. She does admit to consuming a “small” bottle of
vodka on a daily basis at the height of her drinking. She denies
any current alcohol use and is reportedly under the care of a
doctor. She states her current diagnosis is bipolar disorder. She
reports that she hears voices in her head and, at times, verbally
responds to them. Ms. Smith was not able to list the medications
she is currently on, nor are there any recent medical records as
to her current medical conditions. Most recent record is January
2016.Mental Status and Behavioral Observations
Attitude and Behavior: Ms. Smith was friendly and cooperative
throughout the interview. She appeared to respond in a genuine
manner when asked questions. At times, however, she appeared
to be confused with the information requested of her. Her
speech was slurred at times, and she had a glazed look about
her.
Appearance: Ms. Smith appeared neat but casually dressed. She
seemed to show adequate attention to her grooming needs. Ms.
Smith did appear to have a slight odor, seemingly of alcohol.
Quality of Thinking: Ms. Smith’s thinking appears pressured
and unorganized. Her reported history does not follow written
reports; however, she does not appear to understand the
inconsistencies. Her self-report appears to be what she believes
to be her honest answer.
Abstraction Skills: Ms. Smith’s abstract thinking appears very
limited; she was unable to explain how work and play are
similar or why people are put on parole.
Affect and Mood: Ms. Smith appeared docile and cooperative
throughout interview. However, the examiner continually
needed to redirect her and help keep her focused.
Orientation: Ms. Smith was oriented x’s 3.
Memory: Ms. Smith’s memory appears limited as evident in her

4. ability to only repeat 4 numbers forward and 3 backwards.
Attention and Concentration: Ms. Smith appeared to attend to
all tasks at hand.
Judgment and Insight: Ms. Smith’s judgment and insight appear
limited in her inability to follow logical order and recognize
inconsistencies.Intellectual Functioning Testing Results and
Interpretations
Wechsler Adult Intelligence Scale-IV (WAIS-IV)
WAIS–IV Scale Score
Verbal Comprehension 67 (Extremely Low)
Perceptual Reasoning 73 (Borderline)
Working Memory 73 (Borderline)
Processing Speed 100 (Average)
Full Scale 67 (Extremely Low)
General Ability 99 (Average)
Ms. Smith is functioning in the Extremely Low range of
intellect, with her Verbal Comprehension Index score
significantly, but not rarely, lower than her Working Memory
and Processing Speed. In addition, her current functioning is
inconsistent with reported prior achievement and
functioningDiagnostic Report and Treatment Planning
This section presents Ms. Smith’s diagnostic report and
treatment plan. The report is based on the current information
collected about her from a clinical interview conducted, medical
records available, a brief mental status assessment and the
Wechsler Adult Intelligence Scale-IV (WAIS-IV). The
following is revealed:
Ms. Smith’s medical issues began during her spell as a nurse.
She reports that her medical problems led to her terminating a
nurse career she had prior to 2015. Her main problems were
associated with high blood pressure for years. She also
confesses to drinking an alcoholic drink laced with a certain
drug. The following is a summary of her SUD screening results
and assessment. SUD Screening Results
Her SUD screen results indicate a positive drug screen of
benzodiazepines. Her medical history also indicates that she had

5. hypertension, atypical chest pain, inflammatory bowel disease,
acute gastritis as well as alcohol poisoning. Besides having a
history of depression, Ms. Smith also indicates she had a
drinking problem for one year. She indicates that these two
were highly related and whenever she feels depressed she would
look for a “small” bottle of vodka. She reports that she
currently does not take any alcohol. SUD Assessment Results
Ms. Smith admits having had a drinking problem for a year.
During her peak times, she would drink vodka, in what she
described as small amounts. She also agreed to have been taking
OxyContin for pain. Her medical history records also indicate
that she had been diagnosed with alcohol poisoning. Diagnostic
Impressions
303.90 F10.20 Alcohol Use Disorder, Moderate
or Severe
291.2 F10.27 Moderate or Severe Alcohol Use
Disorder with Alcohol-Induced Major Neurocognitive Disorder,
Nonamnestic-Confabulatory Type
305.50 F11.10 Opioid Use Disorder, Mild
307.89 F54 Psychological Factors Affecting Other
Medical Conditions
296.80 F31.9 Unspecified Bipolar and Related
Disorder
293.82 F06.0 Psychotic Disorder Due to
Another Medical Condition with Hallucinations
V62.89 265.8 Religious or Spiritual
ProblemRecommendations
Based on the above, therefore, the following recommendations
are deemed necessary
· A thorough medical history should be created, based on the
story she has told as well as her medical history. There is need
to marry these two so that they speak the same language.
· Ms. Smith’s mental and behavioral assessment suggests that
she also needs to see a psychologist/psychiatrist who will help
her get through her anxiety. This will also improve her
cognitive thinking, further improving her abstraction and

6. judgement skills.
· Ms. Smith should be taken through therapy to reduce the
chances of relapse; given that she is likely an alcoholic. This is
in line with the report she gave about dealing with an alcohol
problem for over a year.
· Medically-Assisted Detoxication is recommended. Bio-
Psycho-Social-Spiritual Assessment
Family History – Current Family: She reported that she used to
accompany her mother to Sunday school at a young age but
stopped. She is 42 years old and currently lives with her mother.
She also has a son.
Family History – Family of Origin: Ms. Smith’s family has
always been based on a strong Christian background. Her
mother always attends church weekly, however, this is not true
for Ms. Smith.
Vocational/Educational/Financial History: Ms. Smith reported
that she had taken a 2-year bachelor’s degree course in Nursing
and had served as a nurse till 2015. However, her family does
not seem to have any financial issues. The fact that she was
taken to school indicates that they might have been in a good
financial position.
Military History: Ms. Smith does not report any military
history.
Legal Assessment: Ms. Smith does not report any legal history.
This may point that she is a law-abiding citizen.
Social/Leisure Assessment: Ms. Smith is a social person and
enjoys having lunch and taking drinks with her friends. Her
attitude and behavior are also friendly and cooperative.
Spiritual/Cultural History: Ms. Smith’s mother is a staunch
Christian who attends church at least once every week. While
Ms. Smith herself used to attend church periodically, she no
longer attends church as often as she should.
Psychological Assessment: Ms. Smith’s psychological
assessment is based on the facts reported from observing her
mental status and behavior. Her attitude and behavior indicate
that she is friendly, honest and cooperative. Her flow of

7. thought, however, indicated that she is tense and appears to be
under pressure all the time, making her judgement questionable.
Her abstraction skills are somewhat limited, so is her memory.
It is important to note that she is attentive, meaning that her
levels of concentration are high.
Sexual History and Orientation: Ms. Smith was married, has a
son, meaning that her sexual orientation is heterosexual. She is
currently single.
Problem Areas
Problem #1: Substance Use
Problem #2: Chronic Pain/Medical Issues
Problem #3: Bipolar Disorder
Problem #4: Treatment Resistance
Problem #5:Relapse Proneness
BPSS Summary
Name: Sally Smith
Marital Status: Single
Residence: N/A
Employment: Unemployed (Former Nurse)
Family Situation: She has a son from a previous marriage and
currently lives with her mother.
Reason for entering treatment: Mental functioning
Alcohol/Drug History: She used to drink a “small” bottle of
vodka. Was once diagnosed with alcohol poisoning
Medical Assessment: Medical history indicates she had
inflammatory bowel disease, acute gastritis, atypical chest pain,
hypertension, and a history of alcohol abuse
Mental Status: Based on the Wechsler Adult Intelligence Scale-
IV (WAIS-IV) IQ test results, results, Ms. Smith’s verbal
comprehension is extremely low. Her perceptual reasoning and
working memory are on the borderline while her processing
speed and full-scale scores are average and extremely low
respectively. Her general mental ability is therefore described
as average.
Psychological Summary: Her attitude and behavior indicates
that she is friendly, honest and cooperative. Her flow of

8. thought, however, indicated that she is tense and appears to be
under pressure all the time, making her judgement questionable.
Relapse Issues: Ms. Smith reports that she is not currently
utilizing substances to cope with her mental and medical issues.
However, her labs and affect report otherwise. Treatment Plan
(Problems 1-5)
PROBLEM #1: Substance Use Disorder
GOAL: Establish a sustained recovery, free from the use of all
mood-altering substances (Perkinson, Arthur, & Bruce, 2014).
Objective 1: Provide honest and complete information from a
chemical dependence biopsychosocial history (Perkinson,
Arthur, & Bruce, 2014).
Intervention 1: Gather a complete drug/alcohol history from the
client, including the amount and pattern of her use (Perkinson,
Arthur, & Bruce, 2014).
Objective 2: Participate in a medical evaluation to assess the
effects of chemical dependence (Perkinson, Arthur, & Bruce,
2014).
Intervention 2: Refer the client for an examination to determine
consequences of substance use (Perkinson, Arthur, & Bruce,
2014).
Objective 2: Cooperate with an evaluation by a physician for
psychotropic medication (Perkinson, Arthur, & Bruce, 2014).
Intervention 2: Assess the need for psychotropic medication for
any mental/emotional comorbidities (Perkinson, Arthur, &
Bruce, 2014).
PROBLEM #2: Chronic Pain
GOAL: Regulate pain without addictive medications (Perkinson,
Arthur, & Bruce, 2014).

9. Objective 1: Describe the nature, history, and impact of chronic
pain, medical issues, and substance abuse (Perkinson, Arthur, &
Bruce, 2014).
Intervention 1: Assess the manifestation of chronic pain/medical
issues, its history, triggers, and methods of coping (Perkinson,
Arthur, & Bruce, 2014).
Objective 2: Cooperate with a thorough medical examination to
rule out any alternative causes for pain and explore treatment
options (Perkinson, Arthur, & Bruce, 2014).
Intervention 2: Refer the client to a physician to undergo an
examination.
Objective 3: Follow through with pain management (Perkinson,
Arthur, & Bruce, 2014).
Intervention 3: Discuss cautious-use of medications to manage
pain (Perkinson, Arthur, & Bruce, 2014).
PROBLEM #3: Bipolar Disorder
GOAL: Alleviate mood symptoms and return to previous level
of effective functioning (Perkinson, Arthur, & Bruce, 2014).
Objective 1: Describe the personal history of mood changes and
associated changes in behavior (Perkinson, Arthur, & Bruce,
2014).
Intervention 1: Encourage client to share her thoughts and
feelings, express empathy, and build rapport while assessing
symptoms of the mood disorder (Perkinson, Arthur, & Bruce,
2014).
Objective 2: Identify depressive behavior patterns and list
several instances in which it led to addiction (Perkinson,
Arthur, & Bruce, 2014).
Intervention 2: Assess the client’s addictive behavior history

10. (Perkinson, Arthur, & Bruce, 2014).
Objective 3: Turn over at least one problem to a higher power
each day (Perkinson, Arthur, & Bruce, 2014).
Intervention 3: Assign the client to turn over one problem each
day to a higher power (Perkinson, Arthur, & Bruce, 2014).
PROBLEM #4: Treatment Resistance
GOAL: Accept the powerlessness and unmanageability that
addiction has brought to life, and actively engage in the
treatment process (Perkinson, Arthur, & Bruce, 2014).
Objective 1: Share the feelings that surround admission to
treatment (Perkinson, Arthur, & Bruce, 2014).
Intervention 1: Probe the reasons why the client is resisting
treatment (Perkinson, Arthur, & Bruce, 2014).
Objective 2: Cooperate with biopsychosocial assessment and
accept the treatment recommendations (Perkinson, Arthur, &
Bruce, 2014).
Intervention 2: Share the results of the assessment, medical
labs, and recommendations with client (Perkinson, Arthur, &
Bruce, 2014).
Objective 3: Provide data for a Stage of Change assessment
(Perkinson, Arthur, & Bruce, 2014).
Intervention 3: Assess client’s position in the Stage of Change
(Perkinson, Arthur, & Bruce, 2014).
PROBLEM #5: Relapse Proneness
GOAL: Maintain freedom from addiction without experiencing
relapse (Perkinson, Arthur, & Bruce, 2014).

11. Objective 1: Write a detailed chemical use history, describing
treatment attempts and the specific situations surrounding
relapse (Perkinson, Arthur, & Bruce, 2014).
Intervention 1: Assign the client to write a chemical use history,
describing her attempts at recovery and the situations
surrounding relapse (Perkinson, Arthur, & Bruce, 2014).
Objective 2: Verbalize the powerlessness and unmanageability
that result from addiction and relapse (Perkinson, Arthur, &
Bruce, 2014).
Intervention 2: Help the client see the powerlessness and
unmanageability that result addiction and relapse using a 12-
step recovery program’s Step 1 exercise (Perkinson, Arthur, &
Bruce, 2014).
Objective 3: Verbalize that continued alcohol/drug abuse meets
the 12-step program concept of insanity (Perkinson, Arthur, &
Bruce, 2014).
Intervention 3: Using a 12-step recovery program’s Step 2
exercise, help the client to see the insanity of her disease
(Perkinson, Arthur, & Bruce, 2014).
Conclusion
Patients with Substance Use Disorder often require therapy
ranging from different aspects. However, before giving it to
them, there is need to conduct a thorough diagnosis of the
patient to ascertain their status. Sally Smith’s case is a perfect
example of how half-done diagnostics can result to an
escalation of the problem rather than solving it. Prior to the
information provided in this diagnostic report, Ms. Smith’s
medical records does not coincide with her medical history.
This, in most cases, makes it hard to conduct effective therapy
that would cure such a patient.
Information needs to be collected from various sources as was
the case in this report. Ms. Smith’s information was collected
through Clinical Interviews, Medical Records, Brief Mental

12. Status Examination and even the IQ-test for adults i.e. Wechsler
Adult Intelligence Scale-IV (WAIS-IV). All these provided
enough information to make the recommendations made for her
to be taken through. The information indicated that she
probably suffers from depression and alcoholism. She also has
memory issues. She can thus get the help she needs from
specific health care practitioners.
References
Hester, R. K., & Miller, W. R. (2003). Handbook of alcoholism
treatment approaches (3rd ed.).
New York, NY: Allyn & Bacon. ISBN: 9780205360642.
Perkinson, R., Jongsma, A., & Bruce, T. J. (2014). The
addiction treatment planner (5th ed.).
Hoboken, NJ: Wiley. ISBN: 9781118414750.