Within the clinical and counseling specialties, psychologists from each discipline work to record their patients’ short-term and long-term goals and progress through the employment of treatment plans. These treatment plans can vary considerably depending on the specialty, setting, providers chosen theory of orientation, and use of evidence-based practices. Overall, treatment plans are designed around the unique and specific needs of the patient. This psychological treatment plan will be designed around the patient from case 19 in Gorenstein and Comer’s (2015) book, Case Studies in Abnormal Psychology.
Behaviorally Defined Symptoms
The patient for which this treatment plan is being developed is a male in his late 60’s to early 70’s. The patient, Fred, has been married to his wife for over 35 years and together they have one adult son. Fred has worked in the construction business for a little over 30 years and has worked for the same company all that time. Prior to the onset of Fred’s current issues, Fred was in relatively good health. Fred has been experiencing problems with his memory and overall cognitive functioning. Fred presents with issues of memory loss, language impairment, and difficulty performing basic tasks (e.g. driving), delusions, agitation, and depression. The patient’s issues have reportedly been taking place over the estimated course of eight years and instead of improving, they have become more severe, and debilitating as time has passed (Gorenstein & Comer, 2015; Nazworth, 2017). In accordance with the Diagnostic and Statistical Manual, Fifth edition (DSM-5), the patient’s symptoms can be attributed to disorders of dementia or Alzheimer’s, possible stroke, major depressive disorder, or purely the natural progression of aging. However, based on the presenting issues, it is probable that Fred is experiencing a major neurocognitive disorder due to Alzheimer’s disease.
Fred has been exhibiting a number of behavioral and cognitive symptoms. Fred’s memory loss has been seen in his forgetfulness, losing/misplacing objects (like putting his glasses in the mailbox), meaning to say one thing, but saying something entirely different, forgetting important dates; for instance, his anniversary and important meetings for work. Fred has also exhibited a severe diminishment in motor function. It began with spilling food on himself, knocking things over, and veering off the road whilst driving. As his condition progressed, Fred began having issues with remember the names of close family members, controlling his emotions, and he quickly progressed to needing the assistance to walk, eat, clothe, and utilize the restroom. Fred began having hallucinations, hearing voices, and he began experiencing symptoms of depression, agitation, and delusions (Gorenstein & Comer, 2015).
Long-Term Goals
A major component in developing successful treatment plans requires the establishment of long-term and short-term goals. When it comes to Alzheimer’s patients, the foremost goal(s) of treatment involve improving the quality of life for the patient and their caregiver(s). Because this is a neurodegenerative disease, care plans are geared toward slowing down the progression of the cognitive decline. Thus, for Fred, long-term goals include supporting successful functioning through the utilization of mental supports and approaches, preserving emotional and physical well-being in an effort to augment cognitive functioning and brain health, and modifying duties and activities to Fred’s cognitive capacity, while simultaneously encouraging him to cooperate with how caregiver(s) and those proving him with assistance (Jongsma, Peterson, & Bruce, 2014) as he navigates his disease.
Short-Term Objectives
In order to achieve long-term goals, treatment plans should consist of distinct short-term objectives tailored to supporting the attainment of the proposed long-term objectives. A few short-term objectives suitable for supporting long-term goals include, having Fred partake in cognitive rehabilitation sessions and complete homework exercises, effecting actions to improve physical health, having Fred challenge himself to successfully perform cognitively difficult tasks that are previously deemed “safe” by clinician, and assisting Fred’s family in making adjustments to cope with Fred’s cognitive deficits (Jongsma, Peterson, & Bruce, 2014). Through the use of each of these short-term objectives, it is believed that Fred will experience less emotion dysregulation, agitation, depression, motor function instability, language impairment, and the progression of cognitive decline will slow considerably. This, in turn, will help alleviate some stress experienced in Fred’s caregiver(s).
Interventions
In order for each short-term objective to be successfully accomplished, Fred would undergo a number of interventions. Fred would be referred for cognitive rehabilitation services in an effort to deal with deficiencies and acquire effective coping skills. To improve physical health and well-being, Fred would be educated on the benefits of physical exercise and then given specific approved exercises to perform each day, along with a healthy diet plan and sleep schedule. To enhance cognitive function and challenge cognitive capacity, Fred will be encouraged to partake in activities; such as, puzzles and reading. Finally, a large portion of Fred’s success and overall well-being is contingent on his family members/caregiver(s). Thus, Fred’s family will be required to attend frequent meetings with Fred’s clinician to become educated on the most commonly encountered challenges and efficacious ways to cope and combat them, along with partaking in spiritual care education.
Three evidence-based theoretical orientations from which appropriate interventions can be selected would include cognitive-behavioral, psychodynamic, and integrative. These orientations are designed to help combat some of the symptoms associated with Alzheimer’s. While there is no cure for AD, symptoms like depression, agitation, delusions, and minor memory and motor functioning issues can be managed with proper therapy and interventions. CBT would work nicely in conjunction with cognitive rehabilitation services, helping to improve Fred’s overall cognitive functioning and coming up with effective coping skills. In addition, CBT would enable Fred to realize how his thoughts impact his behavior. Integrative therapy would be beneficial in juxtaposition with interventions of improving physical health and well-being and challenging cognitive capacity. Integrative therapy opens up different avenues for diverse approaches to helping the patient. Finally, psychodynamic therapy would largely be useful to Fred’s caregiver(s)/family members in helping them understand and come to terms with the severity of Fred’s condition. It would be a great therapy to use in aggregation with having his family become educated in the unique dynamics of the disease and the most common challenges they will likely encounter. Together, therapy and intervention can better prepare family members/caregiver(s) in providing the best care possible to Fred.
Implementing numerous theoretical orientations within this treatment plan enables clinicians to approach the client’s issues from more than just one school of thought. In turn, this makes it possible to treat the patient from a number of avenues. With the complexity of this disease, it is imperative to have a variety of ways to not only help the patient, but also to help the family members through the process of caring for the patient while maintaining their own mental health. With that being said, three treatment modalities that would work in the case of Fred include individual, family, and group. I believe group treatment would be highly beneficial to both Fred and his caregiver(s). It would enable Fred to realize that although his condition can make him feel very isolated and like no one understands what he is going through, there are other people who harness the same condition and are going through all the same experiences and emotions that he is. This sort of psycho-social approach to treatment could really assist in alleviating feelings of depression, anxiety, isolation, and agitation. Further, caregivers could realize that there are other caregivers going through the same experiences as them and can be an additional support system for one another.
In addition to the clinical psychologist, it would be best if Fred met with a psychiatrist and his primary care physician. The psychiatrist could provide medication for symptoms of anxiety and depression in the event that the proposed intervention and therapies do not show enough significant improvement in problematic symptoms. Additionally, Fred should continue to meet with his PCP so that other aspects of his health; such as, blood pressure, cholesterol, and overall physical health can be properly monitored.
Evaluation
It is anticipated that each of the proposed treatment interventions will help improve Fred’s general quality of life, but also the quality of life for his caregiver(s). In a study conducted by Hwang et al. (2015), AD patients were required to partake in computer-assisted cognitive rehabilitation. The findings of the study revealed that patients had significant improvements in areas of attention, orientation, recall, registration, task performance, etc. Overall, it was concluded that this form of intervention has the great potential to help with delaying the progress of memory deterioration and declining cognitive functioning. In another article studying the benefits of physical exercise in AD patients, particularly aerobic exercise, it was discovered by the news reporters that this form of exercise has the great potential to enhance cardiorespiratory fitness and elf-efficacy, and improved both single and dual-task performance (Neurodegenerative Diseases and Conditions, 2017). Due to their being no cure for AD, non-evidence based interventions have been explored and found useful in developing a basis for improved quality of end-of-life care. Exercise is one such non-evidence based treatment that is recognized to harness benefits to the overall health and well-being of all individuals. Exercise is said to release endorphins, which produce that “feel good” sensation and allows us to be more alert and energized. In patients with Alzheimer’s disease, exercise could possibly help reduce functional diminishment. It could also assist in decreasing the risk of falling, and symptoms of agitation and depression (Nazworth, 2017; Primary Psychiatry, 2009), all of which have been experienced by Fred. Additionally, in an interview conducted by Sloan (2013) on Max Wallack, a young man closely acquainted with Alzheimer’s disease due to watching his grandmother go through it, it was revealed by Wallack that activities like jigsaw puzzles really helped patients with this condition. Wallack began doing research after he noticed how his grandmother’s mood would improve after doing jigsaw puzzles and found that puzzles were a great way to boost AD patients’ self-esteem, but also a way to help slow the progression of the disease (Sloan, 2013). Finally, because caring for AD patients can be extremely stressful and both physically and mentally taxing, it is important for caregivers to be as educated and prepared as possible for coping with the many challenges they are sure to encounter. One way to help maintain self-efficacy is through spiritual care education. In a (2017) study conducted by Salamizadeh, Mirzaei, and Ravari, it was found that spiritual care education was highly helpful and valuable in improving self-efficacy in family caregivers of AD patients. This intervention is a way to empower caregivers in an effort to help them sustain the level of energy and dedication needed to provide their loved one with the best quality care. Though Fred’s case seems rather progressive, each of these interventions can be modified to accommodate him and his specific needs.
Evidence-based interventions are crucial to the outcome of treatment plans. In theory, evidence-based interventions are those treatment that have been proven efficacious via outcome assessments. Nevertheless, evidence-based interventions are most effective when they are applied with integrity and when they illustrate a significant change in target behavior. While it is important to keep treatment options open, most successful treatment plans come from the utilization of evidence-based interventions that are backed by research revealing tangible results.
Ethics
Although there are a number of ethical considerations that naturally come with treating any patient, the only ethical dilemma present here would seem to be obtaining informed consent for treatment for Fred. Although there is no mention by Gorenstein and Comers (2015) about Fred’s wife obtaining a Power of Attorney to make decisions for Fred, this would need to be addressed as Fred’s cognitive capacity to make autonomous decisions has been greatly compromised. Because of how severe Fred’s symptoms are, advance directives should be put into place to ensure that Fred’s wishes are carried out in an ethical and honorable fashion. This upholds Principle A: Beneficence and Nonmaleficence. Principle E: Respect For People’s Rights and Dignity, and standard 3.04: Avoiding Harm within the APA’s (2010) ethical principles of psychologists and code of conduct.
Conclusion
In conclusion, it can be said that an effective treatment plan consists of proper evidence-based interventions, an integration of numerous theoretical orientations, and ethical guidelines to direct the treatment plan to successful fruition. In the unique case of Fred, interventions were suggested based on his presenting symptoms and behaviors. These interventions have the potential to be modified as necessary, and can easily be carried out until Fred is no longer able to physically, mentally, or emotionally complete them. The severity and extreme progression of Fred’s condition seems to largely be due to a huge lack of stimulation. Thus, it is the acting clinician’s hope that such interventions will put some life back into Fred and help alleviate some of the stress and burden his wife/caregiver is enduring.
References
American Psychiatric Association. (2013). DSM-5: The diagnostic and statistical manual of mental disorders (5th ed.) [E-book]. Washington, D.C.: American Psychiatric Publishing.
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics/code/principles.pdf
Gorenstein, E. E., & Comer, R. J. (2015). Case studies in abnormal psychology (2nd ed.). New York, NY: Worth Publishers.
Hwang, J.-H., Cha, H.-G., Cho, Y.-S., Kim, T.-S., & Cho, H.-S. (2015). The effects of computer-assisted cognitive rehabilitation on Alzheimer’s dementia patients memories. Journal of Physical Therapy Science, 27(9), 2921–2923. http://doi.org/10.1589/jpts.27.2921
Jongsma, A. E., Peterson, L. M., & Bruce, T. J. (2014). The complete adult psychotherapy treatment planner (5th ed.). Hoboken, NJ: John Wiley & Sons.
Nazworth, J. (2017). Psychiatric Diagnosis: Final paper in PSY 645: Psychopathology.
Neurodegenerative diseases and conditions - Alzheimer disease; new data from university of Copenhagen illuminate findings in Alzheimer disease (effect of aerobic exercise on physical performance in patients with Alzheimer’s disease). (2017, Jan 13). Health & Medicine Week Retrieved from https://search.proquest.com/docview/1855937272?accountid=32521
Primary Psychiatry (2009). Psychosocial-Environmental Treatments for Alzheimer’s disease. Retrieved from http://primarypsychiatry.com/psychosocial-environmental-treatments-for-alzheimeras-disease/
Salamizadeh, A., Mirzaei, T., & Ravari, A. (2017). The impact of spiritual care education on the self-efficacy of the family caregivers of elderly people with Alzheimer's disease. International Journal Of Community Based Nursing & Midwifery, 5(3), 231-238.
Sloan, S. K. (2013, Sep 19). Puzzling project: Max Wallack helps Alzheimer’s patients. Washington Jewish Week Retrieved from https://search.proquest.com/docview/1450244858?accountid=32521
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