For this assignment, you will develop a thorough clinical treatment plan for Kim-Ly. The full case description is here:

Kim-Ly_Case PDF.

Remember that problems, goals, objectives and actions steps are all related directly to the problem. Also, objectives MUST have all necessary components (as described in

Treatment Planning_IDL Module.pptx

).

Assignment Instructions:

Step 1: In a narrative format (double spaced), address the following:

• Identify and describe two problems (of Kim-Ly’s) to be treated clinically. Keep in mind that your description of the problems should reflect some psychodynamic thinking – it is not a rehashing of the story line.
• Explain why you would treat these two problems.

Step 2: In an outline format (single spaced), address the following (this outline section can be single spaced and it is not necessary to make it ‘look’ like a research paper):

• Identify one goal for each of the two problems = a total of 2 goals for this assignment.
• Identify two objectives for each of the goals (based on the problems) = a total of 4 objectives for this assignment.
• Identify 4 action steps for each of the objectives (based on the problems) = a total of 16 action steps for this assignment.
• The outline format can look like this:

  Goal: _____________________________

  Objective: ____________________

  Action Steps_______________

Paper Format:

• In-text citations and references are *not* required for this case treatment plan assignment.
• However, please add an APA-style cover page that follows this APA Student Title Page Guide.
• This paper should NOT include a running head, an abstract, a table of contents, or an appendix.

Font Type and Size:

• A variety of font choices are permitted in APA Style. Use the same font throughout the text of the paper. Options include:

  Sans serif font: 11-point Calibri, 11-point Arial, 10-point Lucida San Unicode
  Serif font: 12-point Times New Roman, 11-point Georgia, normal (10-point) Computer Modern

• For more information: refer to page 44 of the of APA Publication Manual, Seventh Edition, and this APA Style Font resource.
• Ensure the font type and font size of your page numbers are consistent with the rest of your paper. 

Paper Length:

• The entire assignment (written / narrative part and outline part) should be a total of three (3) pages in length (excluding the cover page).
• The written / narrative part should reflect QUALITY CONTENT.

Notes:

To access the rubric for this assignment, select ‘Show

Rubric

‘ from the drop down box located at the upper right hand corner.
Rubric

Kim-Ly’s Treatment Plan (1)Kim-Ly’s Treatment Plan (1)CriteriaRatingsPtsThis criterion is linked to a Learning OutcomeNARRATIVE FORMAT: Identify 2 problem areas for Kim-Ly

 5 pts
This criterion is linked to a Learning OutcomeOUTLINE FORMAT: ONE goal for each problem = 2 Goals

5 pts
This criterion is linked to a Learning OutcomeTWO highly detailes objectives for each goal = 4

 5 pts
This criterion is linked to a Learning OutcomeIdentify FOUR clearly stated Action Steps for each = 16  

5 pts
Total Points: 20 

Kim-Ly Case Scenario
Kim-Ly is a 25 year old 2nd generation Vietnamese woman who comes into counseling at the suggestion of her
female friend who she sees in church weekly. She comes to counseling now because she wishes to move out of
her parents’ home and is quite conflicted about doing so. Kim-Ly has never been in counseling before and her
family does not believe in seeking help from ‘outsiders’ or from agencies. Their belief is that the family takes
care of its own.

Kim-Ly is a petite, thin and attractive woman who currently lives at home with her parents (both in their 40’s),
her two younger sisters (16 & 20) and her younger brother who is 22 years old. The family lives in Orlando and
socioeconomically, the family still struggles but manages to make ends meet and most months can pay their rent
on time. Her parents complain that their landlord is constantly threatening to evict the family and often tells
them that ‘they should return to their own country’. Her parents have owned a small grocery store in Orlando
for about 15 years and have been able to provide basic necessities for the family. Prior to that and up to about
the time that Kim-Ly was 10, the family was quite poor and struggled on a day to day basis, often depending on
relatives. But 15 years ago, Kim-Ly’s father visited his father in Vietnam and while there Kim-Ly’s paternal
grandfather gave her father a small sum of money, enough for the family to purchase the small grocery store
they now own. Her parents have worked very hard and things have gone okay for the family since then. Her
parents however, are always stressed out about paying bills and making ends meet—always fearing that they
will lose their apartment and the store.

Kim-Ly’s parents immigrated to the United States 27 years ago. Kim-Ly was born in New York City where her
parents first lived. The family lived in Vietnamese community in New York City known for incidents where
female children were kidnapped and sent to live as domestic servants in non-Vietnamese homes. Kim-Ly was
taken off the streets at the age of 8 and forced to work in a wealthy woman’s home for two years. After living
there, she managed to escape and found a friend who helped her return to her family. When she returned her
family, especially her father considered her ‘damaged goods’ and felt that Kim-Ly brought shame to the family
as she had been sexually abused repeatedly by the wealthy woman’s boyfriend. The relationship between her
and her father has remained ‘tense’. Her family is now very protective of all the female relatives in the family
as they fear that they too can have the same experience. Right after this incident and when Kim-Ly was 10 years
old, the family moved to Orlando.

She has been educated through the American school system and is bilingual in English and Vietnamese. Kim-
Ly considers herself quite Americanized and has adopted many of the American values, though she seldom
shares those viewpoints with any members of her family. She fears that the family would not approve and that it
would be disrespectful for her to go against her parent’s values and traditions. Her parents are very rooted in the
traditional Vietnamese ways including practicing Buddhism. Kim-Ly is a practicing Catholic and this often
causes friction between herself and other family members. She feels like she’s living a double life: a
Vietnamese life at home that she is not comfortable with and an American life outside her family that she
wishes to pursue but cannot.

Because her parents are so traditional and not accepting of American values and ways, Kim-Ly was not allowed
to date, to leave the house past a certain hour in the evening and was escorted to places by her brother. She has
always been considered a compliant daughter who has been respectful towards her parents. But lately, Kim-Ly
has experienced tense moments and even arguments with her parents about her wish to have an American
boyfriend and her desire to have her own life. She secretly has an American boyfriend who appears to have a
drinking problem and on several occasions has verbally and physically abused Kim-Ly. She has not told anyone
about the abuse she experiences at the hands of her boyfriend. She wishes to get her own apartment but is
tortured by guilt about not following traditional Vietnamese values that include her leaving her parents’ home
married to a Vietnamese man. Lately during these altercations, Kim-Ly has accused her parents of being
physically abusive to her as a child. They respond by pointing out that as parents their responsibility is to
‘discipline’ their children and remind her that the physical discipline made her the successful person she is

today. Kim-Ly often feels rage over this but doesn’t know what to do with the rage so she continues to “keep it
to herself”. She often finds herself (on most days) feeling hopeless and feeling that she is not worth much.

Kim Ly often feels as though she is ‘suffocating’ and is very sad most days. She feels isolated from her peers
and outside of her job as an event planner for the Convention Center and her helping her parents at the store, she
does not have other interests nor does she have many support systems. She is indeed quite successful in her job
but doesn’t feel good about life or feels any joy. Because of these responsibilities she only sees her boyfriend 2x
a week and not for very long. Her anxiety related to her unhappiness and her wish to have a different kind of
life has recently resulted in trouble sleeping, nightmares, anxiety, poor appetite, trouble concentrating on her job
and crying spells. She recently lost her small dog who died of cancer and who she considered her ‘only true
friend’. She feels that she has very low self-esteem. Kim Ly has concerns that she is always tired and not
motivated to do much outside of work and reports that she has felt this way for at least 2 years.

She reports that her supervisor at work has made racist comments about Kim-Ly’s ethnic background and treats
Kim-Ly differently than the other workers. Kim-Ly has attempted to discuss this with her male supervisor, but
he instead has responded with sexual comments about Kim-Ly and has indicated that “life would be easier for
Kim-Ly if she would cooperate with him”. The supervisor also reminds Kim-Ly that she is the youngest
employee and that he doesn’t usually hire anyone under 35 years of age. He reports that he made an exception
to this when he hired Kim-Ly assuming that she would “be a cooperative and friendly employee towards him”.

Kim-Ly has never been hospitalized in a psychiatric hospital nor has she sought out any counseling help
previously. Though she admits that in the past she has thought about wishing she were dead and questioning
why she was ever born. She reports that her mother was seen by a medical doctor years ago for ‘sadness’ and
prescribed medication, which her mother refused to take. She reports that she has been feeling all of these things
more for the past two years.

Kim Ly herself does not like doctors as she fears that she will be given ‘bad news’. She has recently noticed two
lumps in her breasts but cannot afford healthcare to see a doctor. Her parents also cannot afford health care and
do not have any money saved up since all of it goes into maintaining their store and they do not make much a
profit—just enough to pay their mortgage.

She is currently feeling that “something has to change since she cannot go on living this way”.

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SOW 6348
Dr. Ana Leon and Dr. Mary Dillon
UCF School of Social Work
Treatment/Care Planning in Individual Practice

Documentation Training I-Presented by Ana M. Leon, Ph.D., LCSW-University of Central Florida
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Introduction
Review the following slides which highlight key material from the course readings about clinical documentation and treatment planning. They also include a brief video of Hannah, our client for this module.
These slides can most optimally be used as a helpful guide and outline for the required readings in this module. They will help you prepare for doing your mental status exam and treatment plan with Hannah.

Our “Targets” for This Module
Identify essential components of a treatment plan-goals, objectives & action steps
Understand the importance of clients as partners in treatment planning
Practice evaluating treatment plan goals and objectives with a client scenario

Our Client – Hannah (Session One)

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The treatment plan as the foundation for other documentation
Changes in program funding & managed care = need for outcome based treatment plans

The Importance of the Treatment Plan

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What is outcome based evaluation?
impacts/benefits/changes to your clients (as a result of your program/intervention efforts) during and/or after their participation in your programs.
Key question in outcome based evaluation
Has intervention/service made a positive difference in client’s problem/situation?

Formulating Outcome Based Treatment/Service/Care Plans

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Identification of acute/current problems
Goals
Objectives
Action steps

Setting up the Service/Care/Treatment Plan

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Agreed upon by you and client
Broad statements

Goals

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Example of Goals
Decrease depression
Increase socialization skills
Develop appropriate ways for expressing anger
Improve parent-child communication

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Sub-components of goals
Behaviorally specific
Measurable
Objectives

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Change statement
Target behavior/skill/situation
Amount of change
Where will objectives be carried out?
Who will monitor/report change?
How will you measure success?
By when?
Objectives – Continued

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Examples of Objectives
Client will decrease temper tantrums in the classroom from 8x daily to 4x daily as reported by the teacher in the tantrum log and completed by 11/30/13.
Client will improve self-esteem score by 20 points on the Post Rosenberg Self Esteem Scale as reported by therapist by 12/30/13.

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Are sub-components of objectives
Directions/steps on how objectives will be met

Action Steps

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Examples of Action Steps
Client will read and answer questions in chapter 1 of the “victim’s abuse” book & discuss in next individual session.
Client will describe in journal & bring into the next session for discussion the following:
3 incidents that triggered angry responses
client’s responses to triggers

Strategies and Interventions
Make sure that for each problem on your treatment plan you include what evidence based interventions and/or strategies you will use. This should include a general statement that identifies the theory that will guide the treatment.
This should emphasize evidence based research & practice—what works best for a specific problem?
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Frequency of Interventions/Time Frame

Indicate how often you will see client and for how long.
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Diagnosis or problem
Objectives of care, service or treatment
Assessments
Clinician/caseworker
Location of service
Interventions/services

When Developing a Treatment Plan We Consider the Following—Acronym DO A CLIENT MAP (Linda Seligman)

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Emphasis
Who and Number of people involved
Timing-how often and how long
Medication or other medical interventions
Adjunct services
Prognosis
DO A CLIENT MAP-continued