Basic Treatment Plan: Antonio - Case Study Example

Brief Case Summary The presented case is of a 25 year old Caucasian male, Antonio. He has been having sleepless nights following an accident that had happened 3 months earlier and that was causing nightmares. The accident had left his sister badly injured and as he was the driver, Antonio feels guilty and responsible for his sister’s condition. He is withdrawn from his parents and any conversation with them ends up in an argument. Antonio has lost interest in all activities that he was previously involved in before the accident. He no longer finds it necessary to look for a job or concentrate on his career. He is nervous of driving, especially when there are passengers I the car and no longer goes to play his favorite game, soccer, as he has cannot drive to the field. He has turned to drinking alone nearly every night. He no longer has friends, and is girlfriend has left him as a result of his coldness and excessive drinking. He is also not able to control his anger and has been constantly involved in fights. Primary Diagnoses: Post Traumatic Stress Disorder (PTSD) Rationale for Diagnosis: Antonio’s case meets the criteria for Post-Traumatic Stress Disorder. Post Traumatic Disorder is normally characterized by avoidance, emotional difficulties and recall behaviors such as nightmares and flashbacks (Schiraldi, 2009). Antonio’s emotional and behavioral symptoms indicate that he may be suffering from Post-Traumatic Stress Disorder. Antonio feels responsible for the accident that resulted in the injury of her sister. The guilt, deteriorated relationship, arguing with parents, fighting and not going to church are pointers that Antonio is suffering from the disorder. It is the withdrawal and the guilt that Antonio faces that act as pointers to the PTSD. Strengths: Antonio was brought up in a catholic family and lived in a white-collar neighborhood; brought in a Christian family; no academic problems. Supports: His primary care physician who referred him to counseling; His parents since he has moved back to live with his parents who have not blamed him for the accident that resulted in an injury to the sister. Barriers:  The stressor in Antonio’s case is still ongoing. The stressor is her sister’s condition. His sister is still in the intensive care unit and she does not have a good prognosis for recovery. This continues to make him feel responsible for almost killing the sister. Antonio’s friends have also withdrawn from him; the girl she was dating is has also pulled away claiming that Antony is keeping to himself. Medications:  No medication has been given or reported at this time Prognosis: It will depend on whether Antonio’s sister recovers from the condition she is currently in. His sister is still in the Intensive Care Unit and her recovery from the condition will influence how Antonio will be; will also be influenced by provision of other services such as counseling to help him get out of his drinking habit and training of social skills so that he can be able to interact with his friends like he used to do. Long Term Goal: The client will report reduced feeling of guilt and responsibility for the current condition that his sister is in. This will be demonstrated by ability to interact and talk to the parents. He will also be staying at home rather than in the bar where he currently prefers. The client will also be able to interact with his friends like before. (Target Date: 10/8/2015) Objective: The client will feel less guilty on the condition that the sister is in. This will make him spend more time in the house and also talk to his parents while in the house without getting into arguments with them. (Target Date: 10/12/2014) Intervention: The counselor will assist he client express his frustration and guilt about the accident which resulted in injury to the sister. The counselor will help the client talk about it freely and provide empathy and support so that the burden is moved from the client thus reducing the level of guilt. Objective: The client will be involved in fewer fights and will be able to talk to the parents and friends without getting into arguments and fights. (Target Date: 10/2/2015) Interventions: The counselor will teach the client how he can cope with his current behavior and how he can avoid getting into quarrels with those he interacts with. Objective: There will be a reduction in the number of beers that the client consumes and the frequency at which he visits the bar: The client will resume soccer training. (Target Date: 10/8/2015) Intervention: The counselor will teach the client about the dangers of alcohol and on the importance of physical exercise. Differential Diagnosis: Additional diagnoses considered include Major Depressive Disorder and Bipolar Disorder. Major Depressive Disorder was ruled out since the client was not only moody but also felt a lot of guilt. Bipolar Disorder was ruled out since the client has no familiar history of the condition. Racial / Ethnic/ Cultural Considerations: The client is a Caucasian whose parents live in a white collar neighborhood. This means that the family has sufficient resources hence he may feel no need to find a job. The white collar neighborhood may also attribute to his inability to relate with others since in such neighborhoods, the dwellers tend to be more concerned with their own personal issues and business. Relational/Countertransference Issues: Antonio has changed and become argumentative and at times gets into fights. This behavior may be witnessed during the counseling session. However, the counselor needs to talk to the client with empathy and support so that the gilt is reduced and the burden of responsibility that he feels lowered. Risk Factors: Client may hurt others in the fights especially when he is drunk. He also faces the risk of developing other mental illnesses. Reference Schiraldi, G. (2009). The Post-Traumatic Stress Disorder Sourcebook: A Guide to Healing, Recovery and Growth. New York: McGraw Hill Professional. Read More