Initial Treatment Plan: Eliza

A biopsychosocial assessment is important in counseling by enabling counselors to carry out an accurate diagnosis by examining diverse aspects that include physical, emotional, and mental health. Information collected through a biopsychosocial assessment will inform a counselor in making effective decisions related to treatment and support interventions to help the patient regain his/her normal health status (Schwitzer & Rubin, 2015). In the case provided, Eliza Doolittle who is the patient is an 18-year-old female student majoring in engineering. Eliza has been undergoing diverse issues in school which include being caught in the school with alcohol.

This led to her being suspended from the school since the school is an alcohol-free campus. However, the client denies any involvement in alcohol saying that it her friends who were intoxicated. A further analysis of the client reveals that she is currently undergoing some life stressors, addicted to online gaming, and involved in occasional drinking with her friends. This paper analyzes the initial treatment plan for the client.

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Part 1: Intake

During the first session, the client was issued with an intake document that was aimed at acquiring information from the client that include her name, age, presenting problems, information about her family, and current medications that the client may be taking (Schwitzer & Rubin, 2015). An analysis of the collected information indicates that the client has low self-esteem as well as anxiety/stress issues. However, information collected from the client was inadequate and not effective in making an accurate diagnosis since the client did not provide any life stressors that have contributed to her status.

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The client is also not willing to access counseling services as indicated on the client's response on the intake document concerning the reason for seeking counseling.

For the counselor to get conclusive information that will enable him/her to have an accurate diagnosis, he/she should provide the client with a CCM-1 document in an effort of collecting more information about the client's problems (Schwitzer & Rubin, 2015). The CCM-1 document is also helpful in guiding counselors to make effective decisions related to the treatment plans since it provides details on the severity of the presenting problems. Information collected using the CCM-1 document indicates that the patient has mild anxiety, slight sleeping problems, and not feeling close to other people. At the end of the biopsychosocial assessment, some of the questions that need to be answered include what problems does the client have and to what extend have the problems affected the client (Schwitzer & Rubin, 2015). The answers to these questions can be used as the basis for developing an effective treatment plan for the client.

Part 2: Biopsychosocial Assessment

Information collected from the completed biopsychosocial assessment for Eliza indicate that the client has a low self esteem and anxiety issues. These may be attributed to the problems that the client is currently experiencing that include indulgence in alcohol and addiction to online gaming (Brown & Barlow, 2014). The client indicated to experience anxiety for several days, unlike other issues that were rarely experienced or not experienced at all. The client has also sleeping problems as well as relationship issues with other people. The client denied having any drinking problems indicating to only drink occasionally with her friends. Most of the drinking occurrences are because of influence from her friends. She has also no history of past mental issues or under medication for any mental conditions.

No life stressors were indicated originating from the client's family as the client has a good relationship with her family. One of the life stressors presented by the client includes her struggle in making friends in school. Using the DSM and ICD diagnostic criteria, the client has anxiety disorder (Brown & Barlow, 2014). The DSM-5 diagnostic criteria for diagnosing anxiety disorder include excessive anxiety and stress as well as constant worry which may be experienced for several days. This may also be accompanied by difficulty for the client to control the anxiety resulting in other problems to the client that may involve social issues. From the CCM-1 results, the client had a score of 2 indicating mild anxiety with the client avoiding situations that make her nervous (American Psychiatric Association, 2017).

The ICD-10 diagnostic criteria provides some of the symptoms for diagnosing anxiety disorder that include more than 6 months where a patient experiences prominent worry and tension avoiding any situation that may cause fear or anxiety which is the case for the client (Brown & Barlow, 2014). This is further attributed to the sleeping problems and feeling of hopelessness experienced by the client affecting her relationship with other colleagues in school. The initial treatment goals and plan will involve addressing the presenting problems and underlying problems affecting the client (Brown & Barlow, 2014). These may be divided into short-term and long-term treatment goals with the short-term goals focusing on addressing some of the healthcare issues that may be addressed within a short term while other issues such as behavior change are categorized in the long-term goals (Brown & Barlow, 2014).

Another long-term goal may include developing social skills that will help her in improving her relationship with other people as well as being able to make friends in school. The treatment plan includes implementing treatment interventions to help the client in overcoming anxiety as well as help her in controlling her addiction to online gaming (Brown & Barlow, 2014). This will also help her in avoiding influence from her friends to indulge in alcohol. The client is also suffering from stress which needs to also be addressed. The treatment plan may involve weekly counseling sessions as well as medications to address anxiety disorder that will help the client in relaxing and taking control of situations that may make her anxious (Brown & Barlow, 2014).

Part 3: Treatment Planning

The level 02 Cross-Cutting Measure (CCM-2) that can be utilized in future sessions based on the provided information is Level 2-Anxiety-adult (PROMIS Emotional Distress-Anxiety-Short Form) that measures 7 attributes related to anxiety for individuals over the age of 18 (American Psychiatric Association, 2017). The client completes this Cross-Cutting Measure where the counselor gives scores of the different items on the document. The scores are added together to give a total sum of the different items measuring anxiety which are then interpreted to determine the severity of the anxiety disorder (American Psychiatric Association, 2017). This measure is important in counseling since a counselor can be able to identify some of the areas that need to be addressed where effective treatment plans can be developed.

An additional assessment outside of those provided by the APA that would measure what the future counselor is attempting to assess based on the treatment goals/plan is the Hamilton Anxiety Rating Scale (HARS) which is an interview designed to access anxiety in individuals (Porter et al., 2017). This assessment tool assesses the symptoms associated with anxiety with psychic subscale comprising of items that measure subjective cognitive and affective components of anxious experiences (Porter et al., 2017). This can be used to determine the severity of anxiety. The assessment findings can be conveyed to the client and family using effective methods to avoid shock and other negative effects that are attributed to poor methods of communicating these findings to the close parties that are involved in the treatment process (Porter et al., 2017).

This may also impact the implementation of treatment interventions as well as the outcome of the treatment process. One way can involve face-to-face communication where the counselor explains the findings as well as what the results mean for the client (Runyan & Khatri, 2014). Helping the family and the client to understand the findings is an important process that may influence the next course of action. This will provide the client and family members with an opportunity to ask any questions related to the findings as well as participate in the decision-making process to develop the most effective interventions and treatment plan (Runyan & Khatri, 2014). This will also enhance trust and the relationship between the client, her family, and the counselor that has been indicated as important in improving patient outcomes.

Prioritizing the needs of the client is also another important process as this influences patient outcomes and the achievement of the developed treatment goals (Runyan & Khatri, 2014). This can be done by evaluating the presenting problems and their severity. Urgent needs should be given first priority which are needs that have negatively affected the health of the client and may even worsen the condition of the client if not urgently addressed (Runyan & Khatri, 2014). Agreed upon outcomes, measures, and strategies can be formulated through a collaborative approach where the client and her family members are given an opportunity to provide their opinions on these aspects. This will help in developing effective decisions where all parties involved participate in the decision-making process which will also enable the family to support the client in overcoming some of the challenges and problems that she is undergoing (Runyan & Khatri, 2014).

Part 4: Referral

Some of the possible referrals that a counselor can make to help the client in addressing her problems include other qualified and experienced counselors who are adequately skilled to address such issues (Okazaki, Kassem, & Tu, 2014). This is because unskilled counselors may inadequately solve the problems resulting in a relapse where the client goes back to these problems again in the future. Mental issues are sensitive matters that need to be addressed by qualified and skilled personnel due to their impact on the client and family members (Okazaki, Kassem, & Tu, 2014). This will enable clients to access effective counseling services as well as medications that will improve their health.

Referrals can also be done to psychologists who have the knowledge to address mental, social, cognitive, and emotional issues. Psychologists assess, diagnose, and treat individuals undergoing psychological distress as well as mental illnesses (Okazaki, Kassem, & Tu, 2014). Anxiety is one of the conditions that can be addressed by psychologists through psychotherapy and treatment plans based on the client's needs. Psychologists can be accessed in healthcare facilities, mental health clinics while others work independently through private practice (Okazaki, Kassem, & Tu, 2014). Referrals can be addressed with the client by providing the client with a list of some of the referrals where the counselor in collaboration with the client select the most effective referral based on the needs to be addressed, the costs of accessing counseling services, and the proximity of the referred service provider (Okazaki, Kassem, & Tu, 2014).

Counselors can know who to make referrals to through research and recommendations from the current healthcare facility. This can be based on the performance of the service providers as well as the experience of other healthcare professionals (Schwitzer & Rubin, 2015). Healthcare facilities have also assistance programs where counselors can access referral information in addressing certain healthcare needs. Counselors can follow up with the referral by maintaining a close relationship with the client which will allow the counselor to monitor the progress achieved through the counseling process (Schwitzer & Rubin, 2015). This ensures that the counselor continues to support the client during this time which is helpful in achieving the developed treatment goals.


  1. American Psychiatric Association. (2017). Anxiety disorders: DSM-5® selections. Arlington, Virginia: American Psychiatric Association Publishing.
  2. Brown, T., & Barlow, D. (2014). Anxiety and related disorders interview schedule for DSM-5 (ADIS-5). Oxford: Oxford University Press.
  3. Okazaki, S., Kassem, A. M., & Tu, M. C. (2014). Addressing Asian American mental health disparities: Putting community-based research principles to work. Asian American Journal of Psychology, 5(1), 4-12.
  4. Porter, E., Chambless, D. L., McCarthy, K. S., DeRubeis, R. J., Sharpless, B. A., Barrett, M. S., & Barber, J. P. (2017). Psychometric Properties of the Reconstructed Hamilton Depression and Anxiety Scales. The Journal of nervous and mental disease, 205(8), 656-664.
  5. Runyan, C. & Khatri, P. (2014). Collaborative Family Healthcare Association Commentary on the ''Joint Principles: Integrating Behavioral Health Care into the Patient-Centered Medical Home''. Families, Systems, & Health, 32(2), 146-146.
  6. Schwitzer, A. M., & Rubin, L. C. (2015). Diagnosis & treatment planning skills: A popular culture casebook approach. Los Angeles: SAGE.
Updated: May 19, 2021
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Initial Treatment Plan: Eliza. (2019, Nov 17). Retrieved from

Initial Treatment Plan: Eliza essay
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