In psychotherapy, paying attention to details is a crucial issue that a therapist must always ensure. To effectively offer medical assistance to patients, a therapist must lay down guidelines and procedures to ensure that a patient is well treated and the proper medication is administered. The process may involve step-by-step detailed information that a therapist must get from the patient, which includes background information, history of the diseases, any treatment plan that has ever been done before, and even requires knowing a patient’s personal information like age, faith, sex, and other information (Crits-Christoph, & Gibbons, 2021). This paper will, therefore, give insights on how to give a psychotherapy plan on how to provide treatment and diagnosis for Mr Juan by laying a protocol like identifying his information, presenting complaint, history, assessment and diagnosis, differential diagnosis, legal and ethical issues, risk assessment and crisis intervention, case formulation and treatment plan.
Identifying Information
Juan is a Mexican-American male; he is 45 years old and works as a manager at a large bank branch. From the information he is providing, we understand that he is experiencing symptoms of sadness and has withdrawn from doing any activity. In addition, Juan is experiencing other things like loss of appetite, irritability, changes in his appetite, inconvenience in sleep, fatigue, and even having suicidal thoughts like committing death (Jongsma et al., 2021). These symptoms have been occurring to Juan for approximately six months, and they are threatening to worsen every time that passes by. Due to his irritability and emotional problems, His family has persuaded him to seek medical assistance. Juan stated that he has a history of these symptoms that dates back to his early adulthood, during which he sought some treatments. Juan further says he has a damaged relationship with his friends and family. Furthermore, Juan goes on and say that he has two daughters from the marriage. Finally, Juan says that he is a catholic who practices his faith and is ready to incorporate his spiritual faith to aid in his recovery.
Presentation of the Complains
Juan started experiencing these symptoms for the last six months, and they are continuing to worsen as time goes by. For the sake of his family and strained relationship with a friend, he is seeking treatment so that he can recover from the loss of appetite, irritability, inconvenienced sleep, and lack of participation in activities that he loves, such as woodworking and participation running club, fatigue and even having suicidal thoughts (Jongsma et al., 2021). Juan says these symptoms have overwhelmed him in meeting the demands of his position as a branch manager in a large bank. These emotional withdrawals have made Juan have strained relationships between him and his family, especially his wife, friends, and even his colleagues.
History
Juan says that He was born in the United States and is the firstborn, and his family moved to Chicago 12 years before his birth. In Juan’s household, he made sure that he firmly held and stuck to his traditions and cultural practices (Jongsma et al., 2021). It is evident that Juan identifies himself as a staunch catholic who believes in his faith, but lately, that faith is unwavering due to the symptoms that he is having. These symptoms date back to his early adulthood, and that made him seek some medical treatments. Finally, Juan has a wife and two teenage daughters who are all concerned about their dad’s emotional withdrawal, thus advising him to seek medical assistance and treatments.
Assessment and Diagnosis
To assist Juan in getting medical assistance and treatment by considering his information, history, and complaints that he has presented. The clinical assessment criteria that have been deployed are physical assessment; thus, it can be concluded that Juan is suffering from a depressive disorder with recurrent episodes of symptoms. All these are caused by depression and the irritability he is facing (Jongsma et al., 2021). To fully assess depression disorder, a DSM-5-TR diagnosis, which implies the criteria for diagnosis of a disorder, will be applied. Establishing the proper , a two-week plan span will be established, and he must report the feelings that he has. They should at least contain loss of pleasure, depression, and emotional withdrawal. In addition, the feelings might not be limited to weight loss, fatigue, reduced concentration, and recurrent suicidal thoughts.
Differential Diagnosis
Differential diagnosis will ensure that those diseases with the same signs and symptoms as those that Juan is experiencing are not omitted such that we do not narrow our minds only on depressive disorder. Other possible conditions or disorders that Juan might be suffering from may include bipolar and dysthymic disorder because these disorders have similar symptoms (Jongsma et al., 2021). Though it can be proved that from the recurrent experience of similar symptoms over time and the seriousness of these symptoms then, we can conclude that he is suffering from depressive disorder, and we will have to wait until the end of two weeks so that we can establish what he is suffering from.
References
Crits-Christoph, P., & Gibbons, M. B. C. (2021). Psychotherapy process-outcome research: Advances in understanding causal connections. Bergin and Garfield’s handbook of psychotherapy and behavior change, 263-296.
Jongsma Jr, A. E., Peterson, L. M., & Bruce, T. J. (2021). The complete adult psychotherapy treatment planner. John Wiley & Sons.
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