Your assignment is to develop a Treatment Plan based upon the clinical case example of Rafael below. Utilizing course materials and other current professional sources, develop a treatment plan which follows the outline provided below the Case Study description:
Case Study of Rafael:
Rafael is a 35 year old twice divorced father of four who works in the construction field on a random basis. He decided to participate in an assessment and possible treatment after his sixth girlfriend, since his divorce, ended their relationship. His past couple of girlfriends left him after telling him that they were exhausted by his mood changes and behavior. He says that his previous two wives and each of his six girlfriends have told him that they need someone who is “more stable” both in mood and behavior. Rafael reports that some of the things that they have complained about are his affairs with other women and one-night stands with prostitutes and dancers along with his drinking. He shares that he has been drinking more than he is comfortable with in an attempt to manage his “down moods”. He also has concerns about the amount of sexual relationships he is engaging in and the fact that he is at risk for a sexually transmitted disease or death.
Rafael was married for six years to his first wife and three years to his second wife. He has three children with his first wife and one child with his second wife. He shares that while he loved his first wife (she was his high school sweetheart) the second wife he married when she became pregnant after a brief relationship of no more than a couple of weeks. He felt that it was his responsibility to “do the right thing.” He has no contact with his children or ex-wives. He reported that he desires to have a relationship with his children but both ex-wives have told him that until he becomes more stable in his relationships and with his moods and stops drinking that he is not permitted to see his children. Both have reported to him concerns over his relationships with prostitutes and the potential that he may engage in these relationships while being around the children. Rafael stated that his mother described him as a teenager who “went through extreme mood changes. Sometimes he was very happy or “up,” and much more energetic and active than usual, or than other kids his age. Sometimes he was “mopey,” and “much less active than usual”. Rafael remembers his first significant down period at age 17. He recounted approximately 3 “down” episodes a year since then that lasted anywhere from 5-6 weeks each. During these times Rafael experienced daily sadness, daily feelings of hopelessness, daily difficulty getting to sleep and staying asleep, continuous feelings of fatigue and difficulty concentrating. He has been hospitalized two times for suicidal ideations and once for “hearing crazy voices”. Rafael stated that he has no desire to do the things he enjoys, to include bowling and doing home improvement projects, during these times and he does not associate with his friends and family. He reported that this was another major issue with his two wives as they complained that he isolated himself from them and his children during these times. He explained that all his significant others have complained that during his “down” times that he “stays away from them. It is during those time that I think that I don’t deserve them because of the things I have done. Sometimes during those times I am so sad that I don’t even think I should live. I feel like trash.”
Rafael has received treatment for his “down” times several times before. He was prescribed medications but they never seemed to help and in his mid 20’s some of these medications set off a “crazy hyper time” that was more extreme than the happy, energetic periods he was used to experiencing as a child. Over the past 10 years he has experienced approximately 20 “crazy hyper” times (about 2 times a year) where he needed only 2 to 4 hours of sleep and felt great. Daily for approximately four weeks, Rafael would experience racing thoughts, initiate sex multiple times per day with multiple partners (often prostitutes but sometimes individuals he had just met at a bar or club), be very talkative, and socialized non-stop. He would frequent bars and clubs in his spare time almost non-stop. He indicated that during his “hyper” times he would believe he was “king of the world” and that he could do anything he put his mind to but often would not follow through with his phenomenal plans due to a “down” time following these periods of high energy. Twice, towards the end of the four weeks of extreme energy, he began hearing voices and was hospitalized. It was at his first and third “hyper” hospitalizations that the psychiatrist took him off the medications he had been taking and tried him on several medications to “even me out”. He would take the medications for 3-6 months after each hospitalization but when he dipped into a “down” episode he would stop taking the medication. “The drugs had serious side effects such as messing with my sex drive and then I would get depressed anyway… so what was the reason to keep taking the stupid things.”
After the times that Rafael has been hospitalized he has been a client at the local community mental health center. He receives counseling, case management, and psychiatric services. He will comply with treatment immediately after hospitalization but as soon as he starts in another “down” period he will stop attending. Rafael believes that the quality and level of treatment he receives is not helpful and began drinking alcohol 5 years ago to help manage his “down” periods. “When I feel normal I drink 1 12 oz. beer a day, when I am down I would usually drink 5-6 12 oz. beers a day, and when I have those periods of high energy I can hold my own with the best of them. Sometimes during those periods I have drank so much that I blacked out. I do not like drinking so much, but when I am depressed it takes more and more beer to make me forget what a loser I am. And then when I have those “up” periods I am just being one of the guys and partying”. Rafael indicated that one year ago he had a significant “down” period and began drinking 7-8 12 oz. beers per day every day. He has struggled since that time to cut back on his alcohol intake. He has attempted multiple times to cut back and verbally berates himself for not cutting back after the depression lifts. “I used to have a handle on my drinking but for the last year I have felt a bit out of control.” Rafael admitted that this past two girlfriends complained about his drinking and attributed the end of the relationships to his moods, sexual misconduct, and alcohol use. “I would like to stop, but lately when I am not drinking all I think about is the next drink. In fact, I would like to stop having the sexual encounters, also, but when I am not engaged in one of those I often think about the next one and how I will meet someone to engage in the sexual behavior. It is like a drug”. Rafael stated that he is currently in a “down time” and has not had a “hyper time” for over 4 months. He has had two distinct “down episodes” since his last “hyper episode”. Rafael reported that he would like to go back to work full-time someday but his “moodiness”, drinking, and the time he spends trying to find sexual partners have made it impossible to hold a full-time job for longer than six to eight months at a time. “I get by with doing odd jobs but these are becoming fewer and fewer”.
Develop a treatment plan for Rafael by utilizing the following outline:
You have access to the DSM-5 information to inform your Diagnostic Impressions by using this Liberty library link: http://libguides.liberty.edu/content.php?pid=544016&sid=4475341
Once this link opens, scroll down to “Psychiatry Online Journals.” On this site, you will find a wealth of information on the DSM-5. After logging in with your Liberty Username and Password, you may access the main codes necessary for your Diagnosis by doing the following:
III. Treatment Plan Recommendations
Final points to remember:
References: Cite all sources used to develop your plan in current APA style in the body of your paper and on the reference page. Your decisions of diagnosis and treatment recommendations need to have authoritative sources rather than just being your own opinion.
Writing Style/APA: Your paper must be well-organized and free of grammatical errors. Your paper must be in current APA format, with a title page and reference page (no abstract needed for this assignment).
Page Requirements: 5–7 pages for the body of the paper, not including the cover page and reference page(s).