Treatment Plan ~ Jessica K. Bower
Chadron State College ~ Dr. Coffey ~ June 24, 2022

Demographic information

Janine is a 50-year-old, white female with 7 children. Janine identifies as a Christian, but she has not been involved in a church for the last 10 years. Janine is healthy in appearance, although she has a full set of dentures at 50. Janine shows average to above average intelligence and has full physical functioning.
History

Developmental milestones-Janine shared that she met all normal milestones throughout her childhood. Janine graduated from high school, but she chose not to continue to pursue a college degree at a community college, when she became pregnant at 18. Janine has always done well in school. Janine no longer has any desire to pursue any further education.
Social context(s) in which they grew up- Janine grew up in the city with her mother. Janine’s father and mother split up when she was a baby. Janine had all of her physical needs met but remembers feeling like she didn’t get enough time with her mother, as she had little time being a single mother.
Significant events in infancy, childhood, adolescence, adulthood- Janine had a few experiences when she was a toddler that indicated the daycare staff weren’t very attentive or were understaffed. Janine had severe rashes on several occasions and did not seem to like going to daycare. When Janine was 7 years old, her mother had another child who Janine remembers being very jealous of. At the age of 10, Janine was sent to live with her father, due to her difficult behavior. Janine’s mother felt he would better be able to provide consistent discipline for Janine. When Janine was 32 years old, her husband and 2 children from her previous marriage were in a fatal car accident. Both of Janine’s children were killed and her husband was in critical condition for 10 months. Since the accident, Janine has provided most of the care her disabled husband needs, from bathing to eating.
What they were like as a child, adolescent, adult- Janine was often scolded for her behavior as a child, adolescent, and adult. Janine pushed boundaries and did not follow directions with her mother, at school, and any other environment. Janine’s outrageous attention-seeking behaviors made it difficult for anyone in a position of authority over her.
Relationships with parents and any siblings, past and present- Janine’s challenging behavior contributed to strained relationships between her and her mother, father, sister, husbands, and children. Janine is not currently speaking to her mother or sister. Janine left her first husband for her existing husband. They have been married for over 20 years, but their relationship is one of necessity. Janine’s husband was disabled in a car accident 18 years ago and he can no longer function on his own. Janine has a regular relationship with 4 out 7 of her children. 2 of Janine’s children died in a car accident and 1 of her children has cut off contact with her.
Peer relationships, past and present- Janine always had friends throughout her life and interacted socially, with ease. Over the past 15 years, Janine has not made any new friends, but she keeps in touch with an old high school friend. Janine’s closest relationships are with her husband and 4 of their children.
Significant others/partners- Janine has been married to her current husband for 23 years. They have 5 children together. Janine was married to her previous husband for 8 years, until she met her current husband.
Sexuality- Janine has always identified as a heterosexual female. Janine enjoys sexual activities with her husband, which she feels is satisfying for them both. Janine has only been intimate with her two husbands.
Favorite memories/most unpleasant memories- Janine remembers enjoying family trips to visit her grandparents at a lake. She has fond memories of spending time with her cousin, swimming in the lake, and family meals. Janine’s most unpleasant memory is when her mother left her with her dad.
Educational history- Janine did well in school, but never pursued a continued education. She always felt like she was satisfied with raising her children and staying home.
Spirituality- Janine says her faith is very important to her and how she lives her life. Janine is not active in a religious organization but maintains her personal beliefs. Janine does not want her children to go to school because she feels that educational institutions may have a negative influence on her children spiritually.
Vocational history- Janine worked for a year after high school, as a nanny. When Janine found out she was pregnant, she quit this job. Janine has not worked since.
Family health history, including physical and mental health- Janine reports that her grandfather died of heart disease and her grandmother was diagnosed with paranoid schizophrenia, but never followed the prescribed treatment for her disorder. Janine also says that her mother is an alcoholic and her father had epilepsy. Epilepsy killed Janine’s father, due to an accident, at the age of 52.
Date and onset of each symptom- Janine’s grandfather was diagnosed with heart disease at the age of 70, when Janine was 34. Janine’s grandmother was diagnosed paranoid schizophrenia at the age of 47, when Janine was 19. Janine’s grandmother started to experience symptoms at the age of 40 but wasn’t diagnosed until 7 years later. Janine’s mother has never sought treatment for her alcoholism. She started drinking excessively, when Janine was 18.
How they describe themselves- Janine considers herself a mother, wife, and devout Christian. Janine describes herself as creative and strong-willed.
Mental status type information- Janine is functioning mentally, but she says she has had a fear of the dark since she was 19. Janine has experienced an accelerated heart rate, shaking, sweating, nausea, and light-headedness when she is in the dark, without any light. Since then, Janine has adjusted her nightly activities to avoid these experiences. Janine has not driven at night for 18 years and she sleeps with most of the lights on in her home. Janine has not been officially diagnosed by a counselor and she does not want treatment as she feels she is managing her symptoms.
Presenting concern- Janine has come in today, because her husband and her older children are concerned about her. Janine has been hearing voices and believes that there is a special plan for her life. Janine believes that the prince of Syria is one of her old boyfriends in disguise, and he is going to knock on her door and take her back to Syria with him. While in Syria, Janine thinks she will have some special purpose. Janine believes that she receives signs confirming that this will happen. This belief has led to financial instability, neglect of her children’s educational needs and a lack of planning for her family’s future needs. Janine has believed these events will happen for 15 years and has not wavered in her beliefs. Janine is not taking any medication, does not drink or use recreational drugs. Janine does not show signs of depression or mania. Janine’s family are starting to realize that this behavior is not normal and want to help Janine get better.
Janine feels that her families concern is unfounded as they simply lack the faith to believe that these events will take place. Janine feels that there is nothing wrong with her and contends that these events will happen, it is simply a matter of time.
Hobbies, priorities, habits, how they spend their time- Janine enjoys spending time reading, primarily the bible. Janine also enjoys watching movies, going on walks with her family, and cooking. Janine prioritizes her time alone and does not want to be involved in society in a meaningful way. She keeps her family isolated as they spend all their time together.
Anything else that you think is important to know in order to understand one's frame of reference- One of Janine’s daughters left her home at the age of 16, because she did not want to live by her mom’s “rules” anymore. She has been working on her GED and does not have any contact with Janine.
Diagnosis with all criteria outlined in the narrative- Janine has experienced auditory hallucinations and grandiose delusions for 15 years and depressive or bipolar symptoms are not present. Janine also experiences an accelerated heart rate, shaking, sweating, nausea, and light-headedness when she is in the dark. Janine has adjusted her life in order to avoid these feelings. Janine’s diagnosis is Schizophrenia-F20.9 and Panic Disorder- F41.0.
DSM-5 Diagnosis
Janine conforms to DSM criteria for Schizophrenia due to her delusions and auditory hallucinations. Janine has not worked since the onset of symptoms, and she has changed her social interaction patterns. Many of Janine’s interpersonal relationships are strained or non-existent. Janine feels there is nothing abnormal about this behavior and shows no concern. Janine does not like when others question her beliefs, and she blames them for their lack of belief.
Janine conforms to DSM criteria for Panic Disorder due to her physical symptoms including- accelerated heart rate, shaking, sweating, nausea, and light-headedness when in the dark. Janine has changed her nighttime behaviors to avoid any future panic attacks. Janine expresses feeling very afraid when her panic attacks began, but she feels good about her ability to control her environment to avoid these attacks.
Janine’s symptoms differ from other patients diagnosed with Schizophrenia because Janine does not show any signs of disorganized speech, grossly disorganized or catatonic behavior, of other negative symptoms associated with Schizophrenia.
Janine’s symptoms differ from other patients diagnosed with Panic Disorder because Janine does not experience shortness of breath, feelings of choking, chest pain, chills or heat sensations, paresthesia, derealization, fear of losing control or going crazy, or fear of dying associated with Panic Disorder.
When diagnosing Janine with Schizophrenia, Schizoaffective Disorder, Depressive disorder, and Bipolar Disorder were ruled out because Janine does not report any depressive, manic or mood episodes. When diagnosing Janine with Panic Disorder, Specific Phobia was ruled out because Janine does not report a fear of the dark, only a fear of situations that might invoke a panic attack.
Janine is a devout Christian who believes that God communicates with her. This would not be considered an auditory hallucination unless she actually heard an audible voice, which she interpreted as God. Janine does not claim to hear God speaking to her auditorily. Janine’s religious beliefs should not be considered a psychotic feature.
Janine’s grandmother was diagnosed with schizophrenia. Since schizophrenia has a genetic link, this may have made Janine more susceptible to the disorder.  
Gender has not been proven to affect the prevalence of schizophrenia, so Janine’s gender will not impact her diagnosis or treatment. With Panic Disorder, females are twice as likely to develop it and relapse during treatment. Janine’s counseling plan will include relapse prevention.
Janine reports that she would like her relationship with her family members to be better. However, Janine feels that her family needs to adjust their perspective on her beliefs and is not interested in treatment. She attended therapy to prove to them, that she was just fine. Janine does not like her Panic Attacks, but she feels she has them under control. Janine is willing to explore her relationships with her family and learn some coping techniques for panic attacks.
Janine has many strengths that can be integrated into the counseling plan. Janine is cognitively alert and oriented. Janine can think about and explain her experiences coherently. Janine is healthy physically and can function well daily. Janine’s family are supportive and want to help her through this process. Janine has housing, food, and access to medical care. Janine can spend time going through the counseling process and has insurance to cover her treatment.
In order to help integrate Janine’s goals with those of her family or mine as a clinician, I would utilize Motivational Interviewing. Since Janine is not too concerned about her condition, she is not going to agree to a list of apparently irrelevant goals. My first step would be to develop a positive rapport with Janine. Then, I would help her to recognize any discrepancies in her feelings about her experiences. As we were doing this, we would discuss her goal of wanting her family to adjust and explore anyways we could manage or treat her Panic Attacks.
In order to help Janine meet her goals, I would utilize psychopharmacology and psychosocial interventions with Janine. Janine wants to improve her relationships with her family, and this would help her to achieve that goal.
I would regularly evaluate Janine’s progress by having her report on behaviors and ask family members to report on behaviors. Since a lack of awareness is typically present with Schizophrenia, it is difficult for Janine to report on her goals or feelings, but she could report on the number of delusional behaviors and auditory hallucinations she experienced. I would have Janine report on her episodes of Panic Attacks and feelings about these attacks.
Treatment Plan
Individual- Janine comes from a similar cultural background as I do, and she is close to the same age as me. I can identify with Janine’s roles as mother and wife. I do not anticipate any issues of countertransference, as I feel I can be object with Janine and help her reach her goals.
Contextual Assessment- Janine is a 50-year-old, white female with 7 children. Janine identifies as a Christian, but she has not been involved in a church for the last 10 years. Janine is healthy in appearance, although she has a full set of dentures at 50. Janine shows average to above average intelligence and has full physical functioning. Janine is lower class, but she has all her physical and immediate needs met. Janine is a heterosexual who has been married for 23 years to her current husband and the father of 5 of her children. Janine has no history of cognitive or physical disabilities. Janine is a devout Christian and her faith is an important part of her life.

Assessment and Diagnosis

Janine’s diagnosis is Schizophrenia and Panic Disorder. Janine does not present with disorganized speech, grossly disorganized or catatonic behavior, of other negative symptoms associated with Schizophrenia. Janine does not present with shortness of breath, feelings of choking, chest pain, chills or heat sensations, paresthesia, derealization, fear of losing control or going crazy, or fear of dying associated with Panic Disorder.
Janine’s appearance, affect, psychomotor activity, speech, orientation and memory do not seem to be affected by her symptoms. Janine is in good physical health.
Necessary Level of Care- Janine’s treatment will consist of community or outpatient treatment, unless family members report behaviors which may be harmful to Janine or others, or counselor observes new behaviors that could be potentially harmful. Janine’s treatment level is- 1.0
Strengths

Janine has the support of her family. She is also cognitively and physically functioning well. Janine has her basic financial needs met and she can engage in therapeutic services.

Treatment Approach

Janine’s treatment approach will include psychopharmacology, psychosocial interventions, individual therapy, and family therapy.

Aims and Objectives of Treatment
Janine will keep a record of every time she hears an auditory voice, for the next 4 weeks.
  Janine will take her prescribed medicine everyday as prescribed, for the next 4 weeks.
  Janine will attend individual therapy 1x per week, for the next 4 weeks.
  Janine will attend family therapy 1x per week, for the next 4 weeks.
  Janine will attend a local church 1x per week, for the next 4 weeks.
Janine will discuss exposure therapy and medication options for panic attacks, with therapist, and decide which course of action she would like to take.

Research-Based Interventions/Treatments

Psychopharmacology has proven to be effective in decreasing delusions and hallucinations in patients with schizophrenia. The goal of treatment with schizophrenic patients is a better level of functioning and reduced intensity in symptoms. Education on social skills training and meeting financial needs are also helpful for patients with schizophrenia. Exposure therapy and medication have proven to be effective treatments for panic attacks.

Therapeutic Support Services- Janine’s support services include a social worker, psychiatrist, local church, and a family therapist.