Write a 500- to 750-word paper discussing the results of the Cross-Cutting Measures. Include the following in your paper: 1.The purpose of each cross-cutting measure

Psychological Testing Instrument
Order Description
The case study to answer by is attached as a file here
Complete the appropriate Level 1 cross cutting measure from the DSM-5. The Cross-Cutting Measures can be found on the Online Assessment Measures page of the American Psychiatric Association website.
Once the Level 1 Cross-Cutting Measure is completed complete the relevant Level 2 Cross-Cutting measure.
Write a 500- to 750-word paper discussing the results of the Cross-Cutting Measures. Include the following in your paper:
1.The purpose of each cross-cutting measure
2.How these measures are administered in practice
3.The results of each measure for the chosen case study
4.The implications of the results for treatment of the person in the case study
Include at least two scholarly references in your paper.
Prepare this assignment according to the APA guidelines found in the APA Style Guide located in the Student Success Center. An abstract is not required.
Case 5.10
The Golden Girls Sophia Petrillo
Introducing the Character
Sophia Petrillo is the eldest character of the four-woman ensemble cast of NBCs The
Golden Girls which aired between 1985 and 1992. Sophia was played by the late
actress Estelle Getty. The show was set in Miami Beach Florida at the home of
Blanche Devereaux a close friend of Mrs. Petrillos older daughter Dorothy played
by the late comic actress Bea Arthur. At the beginning of the series we meet Sophia
who was forced out of the Shady Pines Retirement Home following a mysterious fire.
Later we learn that the fire was caused inadvertently by Sophia and her Shady Pines
roommate who were secretly making smoresthe hot dessert snack that combines
graham crackers marshmallows and melted chocolateon a hotplate. Throughout
the series Sophia was the typically unflappable and perennially caustic house
mother whose stroke earlier in life rendered her permanently annoying according
to her daughter Dorothy. During each episode Sophia is full of bristling commentary
on the plight of women the importance of traditional family values and other
assorted topics including love sex relationships and religion. The following basic
case summary and diagnostic impressions present our view of Sophia as she begins
to experience multiple cognitive deficits later in her life.
Basic Case Summary
Identifying Information. Sophia Petrillo is an 85-year-old widowed Italian American
woman who lives with her 63-year-old daughter and two other women a household
group she refers to as the Golden Girls. Medical reports indicate that Mrs. Petrillo
is in good health and of good strength for her age with no indications of diseases
of the central nervous system or other systems; however she did experience and
apparently recover from a stroke several years ago. She presents as a woman of
diminutive stature and frail appearance; however her caustic wit contributes to the
impression that she is much larger in stature.
Presenting Concern. Mrs. Petrillo was accompanied to the Greater Miami Counseling
Center by her daughter Dorothy who was concerned that Mom has finally lost it.
Although Mrs. Petrillo is reportedly capable of taking care of her daily needs her
daughter has noticed that of late Mom has been particularly sarcastic says she cant
remember who I am and walks around the house at night calling out the name of
my father. She appears to have forgotten her housemates names at times. On several
occasions Dorothy found her mother on her knees in the garden planting tomato
seeds which would not otherwise be disturbing; however it was wintertime and Mrs.
Petrillo was dressed only in her nightgown. Her daughter also reported that Mrs.
Petrillo no longer seems able to plan meals follow a recipe or organize her weekly
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Case 5.10 The Golden Girls Sophia Petrillo ? 275
shopping and other outings. Dorothy reported that Mrs. Petrillos symptoms had
become gradually more noticeable to her and her housemates over a long while.
Background Family Information and Relevant History. Sophia Petrillo was born in
Sicily Italy the middle of five children to Don and Eleanor. Mrs. Petrillo reportedly
was successful in school and enjoyed her studies. She was planning to become a
nurse (one of the few vocations open to women in her context) when instead at her
parents insistence she changed plans and prepared to marry her parents selection
of a potential husband. However deciding at the last minute that I wasnt going to
live somebody elses life Mrs. Petrillo left her fianc at the altar and came to New
York. Within several months she met and married Salvatore Petrillo who worked by
day in a grocery store but who also is suspected of having some minor involvements
with local organized crime.
Over the next several years Mrs. Petrillo and Salvatore had three children:
Dorothy who along with her husband had one child; Gloria who briefly married into
wealth; and Phil a devoted husband and father who unbeknownst to the family
was cross-dressing. Mrs. Petrillo worked tirelessly to raise her children particularly
after her husband was killed in gang violence. She worked in a number of vocations
during her 30s 40s and 50s including at Bloomingdales in the perfume department
in a neighborhood wine store as a front desk manager at a Holiday Inn on
Staten Island New York as well as a substitute teacher in the same school where
Dorothy was working.
Over the years Mrs. Petrillo had endeared herself to friends and coworkers with
her sharp wit ever-ready smile and willingness to lend a hand to others in need. All
were shocked when shortly after her 65th birthday Mrs. Petrillo began to experience
disturbing and erratic behaviors and the seeming inability to restrain herself from
making hurtful and sarcastic comments about other people. These changes were
followed soon after by a stroke that left her partially paralyzed on the left side of
her body. Her speech much to the chagrin of her daughter was left intact.
Soon after the stroke Mrs. Petrillo was moved to the Shady Pines Nursing Home by
her daughter who was surprised when her mother after only 6 months in the facility
married fellow resident Max Winestock. When the facility burned to the ground Mrs.
Petrillo was invited to live with Dorothy who was not able to accommodate Mr.
Winestock. He was subsequently transferred to another facility and over the years he
and Mrs. Petrillo maintained a very cordial (and occasionally sexual) relationship.
As of this writing Mrs. Petrillo had been comfortably living with her daughter and
two other housemates for 2 years and was appreciative of the opportunity to in her
words Be with the people I love . . . even though they are a pain in my royal ass if
you know what I mean.
Problem and Counseling History. Mrs. Petrillo was accompanied to the intake by
her daughter Dorothy who had her arm wrapped gently around her mothers shoulder
and who escorted her to one of the interviewing chairs. As she sat down Mrs.
Petrillo pushed her daughters hand away and brusquely said I can sit down myself;
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276 ? DIAGNOSIS AND TREATMENT PLANNING SKILLS
stop treating me like an old woman. Each time that Dorothy attempted to relate
details of her mothers most recent experiences Mrs. Petrillo interrupted her and
announced Oh now youre going to talk for me also.
Mrs. Petrillo was a very animated articulate and astutely oriented octogenarian
who freely and easily offered information and details about her life both recent and
remote. Placid at times while irritable at others she proudly proclaimed Ive lived
this long without any help from anyone and I just need them to know that Im fine.
Mrs. Petrillo denied experiencing the personality and behavioral changes that her
daughter noticed in which regard she said I get a little more tired than usual but
Id like to see if they have half the spirit that I do when they get to be my age . . . with
or without a stroke.
Goals for Counseling and Course of Therapy to Date. At the end of the intake
session Mrs. Petrillo was invited to participate in the Golden Girls Senior Activity
Program which includes social and craft activities cooking classes as well as individual
and group counseling. Upon hearing this Mrs. Petrillo proclaimed Oh so
now you think Im nuts and want to lock me in this crazy joint no way Jos. She
got up from her chair turned her back and walked abruptly out of the room. Her
daughter agreed to encourage Mrs. Petrillo to return for further assessment and also
agreed to participate in an in-home evaluation conducted by a licensed clinical
social worker. The primary goals of the follow-up interview and in-home evaluation
will be (a) to confirm clinically significant decline in the form of memory loss and
other cognitive deficits; and (b) assist the client and her daughter in determining an
appropriate plan of action.
Diagnostic Impressions
331.83 (G31.84) Mild Neurocognitive Disorder Due to Possible Alzheimers Disease
With Mild Behavioral Disturbance (Agitation); 436 (I63.9) History of Stroke (CVA).
Other factors: Widowed; V61.03 (Z63.5) Disruption of family by separation or
divorce separated from her current husband.
Discussion of Diagnostic Impressions
Sophia Petrillo was accompanied to the Greater Miami Counseling Center by her
daughter because she was concerned that Sophia was experiencing memory
impairment (forgetting her daughters and her housemates names) and disturbances
in her everyday activities (gardening in a nightgown late on a winter night;
failing to follow the steps of a familiar recipe in the kitchen). Her daughter
thought Mrs. Petrillos memory loss and other behavioral changes had developed
gradually over time.
The DSM-5 section Neurocognitive Disorders contains a variety of mental disorders
featuring significant deficits in cognitive abilities that signify a clear change from
a persons previous level of cognitive functioning. Included are delirium (disturbance
in consciousness) due to substance use a medical problem or multiple sources; and
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Case 5.10 The Golden Girls Sophia Petrillo ? 277
major and mild neurocognitive disorders (impairment in memory plus multiple other
cognitive deficits) due to various medical etiologies or sources (e.g. Alzheimers
Disease Traumatic Brain Injury HIV infection Parkinsons Disease Huntingtons
Disease etc.). One of these disorders that is especially important to the everyday
practice of counseling professionals who work with older adults in various inpatient
and outpatient settings is Neurocognitive Disorder Due to Alzheimers Disease.
In this case example Mrs. Petrillo presented multiple cognitive deficits later in her
life manifested by memory impairment in the form of an inability to recall previously
learned information and other deficits in the form of disturbance in executive functioning
(such as planning organizing and following sequences). The onset of Mrs.
Petrillos cognitive decline was gradual continuing and causing impairment in
social and other functioning. Although she does have a history of stroke the current
symptoms of cognitive decline were not attributable to the stroke or to any other
medical condition or substance use. In such cases the diagnosis is Mild Neurocognitive
Disorder Due to Possible Alzheimers Disease. Mrs. Petrillos cognitive symptoms
were accompanied by behavioral disturbances that were clinically significant such
as gardening on a winter night and increased agitation. Therefore the specifier is
With Behavioral Disturbance and the subtype is Mild.
Distinguishing among physical cognitive affective and behavioral factors influencing
changes in older adult clients functioning requires the counselors special
attention (Schlossberg 1995). In the case of Neurocognitive Disorder Due to
Alzheimers Disease perhaps the most important consideration regarding differential
diagnoses pertains to etiology: Neurocognitive Disorders due to a general medical
condition due to substance use and due to multiple known etiologies might be
considered. However in Mrs. Petrillos case there is no evidence from lab tests or
physical examinations to suggest any of these causes. Generally speaking
Schizophrenia also might be a differential consideration when considering symptoms
of a Neurocognitive Disorder; however in Mrs. Petrillos case there is no lifelong
history at all of Schizophrenia. Alternatively Major Depressive Disorder may
feature impairment in memory concentration and thinkingand clinicians are
alerted that depressive disorders may be difficult to differentiate from cognitive
impairment in older adults (Chapman & Perry 2008). However in Mrs. Petrillos
case no other symptoms of a mood disorder were observed or reported and the
nature of and gradual onset of symptoms conform to the criteria for Mild
Neurocognitive Disorder Due to Possible Alzheimers Disease.
To finish the diagnosis Mrs. Petrillos history of stroke is listed alongside her primary
mental health diagnosis and her important family and social stressors are
emphasized in the Other factors section. This supplemental information is consistent
with the primary diagnosis describing Mrs. Petrillos onset of concerns.
Case Conceptualization
During Mrs. Petrillos first visit to the Greater Miami Counseling Center the intake
coordinator obtained present-day and background information about the behaviors
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278 ? DIAGNOSIS AND TREATMENT PLANNING SKILLS
and consequences leading Mrs. Petrillos daughter at this point to seek professional
consultation. Based on the intake visit neuropsychological testing and medical
record information the coordinator developed diagnostic impressions of Mild
Neurocognitive Disorder Due to Possible Alzheimers Disease With Mild Behavioral
Disturbance. A case conceptualization next was developed. Whereas the purpose of
diagnostic impressions is to describe the clients concerns the goal of case conceptualization
is to better understand and clinically explain the persons experiences
(Neukrug & Schwitzer 2006). In turn case conceptualization sets the stage for
treatment planning. Treatment planning then provides a road map that plots out
how the therapy team at the day center and the client expect to move from presenting
concerns to positive outcomes (Seligman 1993 p. 157)helping Mrs. Petrillo
better control the symptoms of Neurocognitive Disorder maintain better daily functioning
and continue as much satisfying independent life activity as possible
(American Association for Geriatric Psychiatry 2006).
When forming a case conceptualization the clinician applies a purist counseling
theory an integration of two or more theories an eclectic mix of theories or a
solution-focused combination of tactics to his or her understanding of the client. In
this case the intake coordinator based his conceptualization on psychotherapeutic
integration of two theories (Corey 2009). Psychotherapists very commonly integrate
more than one theoretical approach in order to form a conceptualization and
treatment plan that will be as efficient and effective as possible for meeting the
clients needs (Dattilo & Norcross 2006; Norcross & Beutler 2008). In other words
counselors using the psychotherapeutic integration method attempt to flexibly
tailor their clinical efforts to the unique needs and contexts of the individual client
(Norcross & Beutler 2008 p. 485). Like other counselors using integration
Mrs. Petrillos clinician chose this method because he had not found one individual
theory that was comprehensive enough by itself to address all of the complexities
range of client types and specific problems seen among his everyday
caseload (Corey 2009 p. 450).
Specifically the intake coordinator selected an integration of (a) Behavior
Therapy and (b) Cognitive Stimulation Therapy. He selected this approach based on
Mrs. Petrillos onset of Neurocognitive Disorder symptoms and his knowledge of
current outcome research with clients experiencing these types of concerns
(Anonymous 2004 2007). According to the research Behavior Therapy is one treatment
approach indicated when assisting clients to reduce and manage their affective
and behavioral symptoms and the consequences of these symptoms for
themselves and family members and caretakers (Ayalon Gunn Feliciano & Arean
2006; Livingston et al. 2005; Spector Davies Woods & Orrell 2000; Spira &
Edelstein 2006) whereas an integrated approach emphasizing Cognitive Stimulation
is indicated to strengthen their cognitive abilities by strengthening memories least
affected by neurocognitive decline namely memories of early life (Woods Spector
Jones Orrell & Davies 1998). The counselor used the Inverted Pyramid Method of
case conceptualization because this method is especially designed to help clinicians
more easily form their conceptual pictures of their clients needs (Neukrug &
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Case 5.10 The Golden Girls Sophia Petrillo ? 279
Schwitzer 2006; Schwitzer 1996 1997). The method has four steps: Problem
Identification Thematic Groupings Theoretical Inferences and Narrowed Inferences.
The counselors clinical thinking can be seen in Figure 5.10.
Step 1: Problem Identification. The first step is Problem Identification. Aspects of
the presenting problem (thoughts feelings behaviors physiological features) additional
areas of concern besides the presenting concern family and developmental
history in-session observations clinical inquiries (medical problems medications
past counseling substance use suicidality) and psychological assessments (problem
checklists personality inventories mental status exam specific clinical measures) all
may contribute information at Step 1. The counselor casts a wide net in order to
build step 1 as exhaustively as possible (Neukrug & Schwitzer 2006 p. 202). As can
be seen in Figure 5.10 the intake coordinator identified not only Mrs. Petrillos
prominent signals of the early onset of Alzheimers-related neurocognitive decline
(irrational behavior memory losses reduced planning and organizing abilities etc.)
but also important strengths events and other aspects of her previously successful
lifetime adjustmentall of which were important to describing her clinical situation.
Step 2: Thematic Groupings. The second step is Thematic Groupings. The clinician
organizes all of the exhaustive client information found in Step 1 into just a few
intuitive-logical clinical groups categories or themes on the basis of sensible common
denominators (Neukrug & Schwitzer 2006). Four different ways of forming the
Step 2 theme groups can be used: Descriptive-Diagnosis Approach Clinical Targets
Approach Areas of Dysfunction Approach and Intrapsychic Approach. As can be
seen in the figure the intake coordinator selected the Clinical Targets Approach. This
approach sorts together all of the Step 1 information according to the basic division
of behavior thoughts feelings and physiology (Neukrug & Schwitzer 2006 p. 205).
The clinician grouped together: (a) cognitive difficulties (gradual memory loss gradual
confusion reduced planning and organizing functions) and (b) behavioral and
affective difficulties (erratic behaviors and decisions less able to follow plans
increased sarcastic responses). Mrs. Petrillos clinician believed that in her case the
Clinical Targets Approach was the most effective bridge between Mrs. Petrillos various
symptoms and the theoretical inferences that would be needed later in his
conceptualization pertaining to the early onset of Mild Neurocognitive Disorder Due
to Possible Alzheimers Disease.
So far at Steps 1 and 2 the intake coordinator has used his clinical assessment
skills and his clinical judgment to begin critically understanding Mrs. Petrillos needs.
Now at Steps 3 and 4 he applies the theoretical approach he has selected. He
begins making theoretical inferences to explain the factors leading to Mrs. Petrillos
issues as they are seen in Steps 1 and 2.
Step 3: Theoretical Inferences. At Step 3 concepts from the counselors theoretical
integration of two approachesBehavior Therapy and Cognitive Stimulationare
applied to the factors causing and the mechanisms maintaining Mrs. Petrillos
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280 ? DIAGNOSIS AND TREATMENT PLANNING SKILLS
1. IDENTIFY AND LIST CLIENT CONCERNS
Medical history of stroke
Widowed from
rst husband
Separated from second husband
Living in family arrangement with
daughter and housemates
History of active independent living
Irrational behavior
Wintertime nighttime gardening in
nightgown
Reduced ability to plan menus
Reduced ability to follow a recipe
Reduced ability to organize shopping & outings
Periodic loss of memory of daughters name
Periodic loss of memory of housemates names
Calling for deceased husband
Increased sarcasm beyond baseline
Gradual onset of symptoms and disturbances
2. ORGANIZE CONCERNS INTO LOGICAL THEMATIC GROUPINGS
1. Cognitive difficulties: gradual memory loss gradual confusion reduced
planning and organizing functions
2. Behavioral and affective difficulties: erratic behaviors and decisions less
able to follow plans increased sarcastic responses
3. THEORETICAL INFERENCES: ATTACH THEMATIC
GROUPINGS TO INFERRED AREAS OF DIFFICULTY
Psychotherapeutic Integration
Behavioral Therapy
As Neurocognitive-related declines
progress Mrs. Petrillo reduces
awareness of antecedents and
consequences of her behaviors
Cognitive Stimulation Therapy
As Neurocognitive-related declines
progress Mrs. Petrillo experiences
various types of cognitive losses at
different rates of decline
4. NARROWED INFERENCES: SUICIDALITY
AND DEEPER DIFFICULTIES
Psychotherapeutic Integration
Behavior Therapy
Mrs. Petrillos problematic
behaviors may be responsive
to enhanced behavioral
intervention such as greater
daily structure practice and
exercises and enhancing early
reminiscences strategies to
compensate for early memory
loss
Cognitive Stimulation Therapy
Mrs. Petrillos cognitive losses may
be responsive to stimulation such
as joining in activities with others
focused intellectual practice and
exercises and enhancing early
reminiscences
Figure 5.10 Sophia Petrillos Inverted Pyramid Case Conceptualization: Psychotherapeutic
Integration of Behavior Therapy and Cognitive Stimulation Therapy
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Case 5.10 The Golden Girls Sophia Petrillo ? 281
functioning. The counselor tentatively matches the theme groups in Step 2 with this
theoretical approach. In other words the symptom constellations in Step 2 which
were distilled from the symptoms in Step 1 now are combined using theory to show
what are believed to be the underlying processes or psychological mechanisms of
Mrs. Petrillos current needs (Neukrug & Schwitzer 2006; Schwitzer 1996 1997).
First Behavior Therapy was applied primarily to clinically thinking through Mrs.
Petrillos needs regarding her behavior and affective responses. As a conceptual
approach Behavior Therapy focuses closely on describing and understanding what
behaviors (including affective responses) are occurring when and how they are
occurring what the antecedents and consequences (i.e. what leads to the behavior
and what results from the behavior) of the behaviors areand in turn what may be
altered or changed in the behavioral chain to improve these responses; in other
words the model focuses conceptually on the specific factors influencing and resulting
from current behaviors and methods of modifying these factors (Lazarus 2005
2008; Martell 2007; Wolpe 1990). In the more specific situation of clients experiencing
the onset of neurocognitive decline related to Alzheimers disease the conceptual
focus may be on the behavioral contexts associated with compensating for
memory losses in daily functioning (written cues visual cues daily structure reality
orientation through using the persons name etc.) (Spector et al. 2000; Woods
2004; Woods et al. 1998) and the issues or events that cue emotional outbursts
depression or anxiety or other problems (Ayalon et al. 2006; Livingston et al. 2005;
Spira & Edelstein 2006). As can be seen in Figure 5.10 when Mrs. Petrillos intake
coordinator applied these concepts she developed the following Step 3 inference:
As neurocognitive-related declines progress Mrs. Petrillo reduces her awareness of
antecedents and consequences of her behaviors.
Second Cognitive Stimulation was applied primarily to clinically thinking through
Mrs. Petrillos needs regarding her cognitive losses. As a conceptual approach
Cognitive Stimulation Therapy focuses closely on describing and understanding
what memory losses and other cognitive declines are occurring in what domains
and in what order and what ratesand in turn what may be altered to mitigate
minimize or slow these declines (Anonymous 2004 2007). As also can be seen in
the figure when Mrs. Petrillos intake coordinator additionally applied these concepts
she developed a further Step 3 inference as follows: As neurocognitive-related
declines progress Mrs. Petrillo experiences various types of cognitive losses at different
rates of decline.
Step 4: Narrowed Inferences. At Step 4 the clinicians selected theory continues to
be used to address still-deeper issues when they exist (Schwitzer 2006 2007). At
this step still-deeper more encompassing or more central causal themes are
formed (Neukrug & Schwitzer 2006 p. 207). Mrs. Petrillos counselor continued to
use a psychotherapeutic integration of two approaches.
First continuing to apply Behavior Therapy concepts at Step 4 the intake coordinator
presented a single deepest theoretical inference that she believed to be most
fundamental for Mrs. Petrillo from a behavioral perspective: Mrs. Petrillos problematic
behaviors may be responsive to behavioral intervention such as greater daily
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282 ? DIAGNOSIS AND TREATMENT PLANNING SKILLS
structure reinforcing reality orientation and other behavioral strategies to compensate
for early memory loss. Second continuing to apply Cognitive Stimulation the
coordinator presented a single deepest theoretical inference that she believed to be
most fundamental for Mrs. Petrillo regarding cognitive functioning: Mrs. Petrillos
cognitive losses may be responsive to enhanced stimulation such as joining in activities
with others focused intellectual practice and exercises and enhancing early
reminiscences. These two narrowed inferences together form the basis for understanding
Mrs. Petrillos current counseling situation.
When all four steps are completed the client information in Step 1 leads to logicalintuitive
groupings on the basis of common denominators in Step 2 the groupings
then are explained using theory at Step 3 and then finally at Step 4 further deeper
explanations are made. From start to finish the thoughts feelings behaviors and
physiological features in the topmost portions are connected on down the pyramid
into deepest dynamics.
Treatment Planning
At this point Mrs. Petrillos clinician at the Greater Miami Counseling Center has
collected all available information about the problems that have been of concern to
her and her daughter. Based upon this information the counselor developed a
DSM-5 diagnosis and then using the inverted pyramid (Neukrug & Schwitzer
2006; Schwitzer 1996 1997) formulated a working clinical explanation of Mrs.
Petrillos difficulties and their etiology that we called the case conceptualization.
This in turn guides us to the next critical step in our clinical work called the treatment
plan the primary purpose of which is to map out a logical and goal-oriented
strategy for making positive changes in the clients life. In essence the treatment
plan is a road map for reducing or eliminating disruptive symptoms that are impeding
the clients ability to reach positive mental health outcomes (Neukrug &
Schwitzer 2006 p. 225). As such it is the cornerstone of our work with not only Mrs.
Petrillo but with all clients who present with disturbing and disruptive symptoms
and/or personality patterns (Jongsma & Peterson 2006; Jongsma Peterson &
McInnis 2003a 2003b; Seligman 1993 1998 2004).
A comprehensive treatment plan must integrate all of the information from the
biopsychosocial interview diagnosis and case conceptualization into a coherent
plan of action. This plan comprises four main components which include (1) a
behavioral definition of the problem(s) (2) the selection of achievable goals (3) the
determination of treatment modes and (4) the documentation of how change will
be measured. The behavioral definition of the problem(s) consolidates the results of
the case conceptualization into a concise hierarchical list of problems and concerns
that will be the focus of treatment. The selection of achievable goals refers to assessing
and prioritizing the clients concerns into a hierarchy of urgency that also takes
into account the clients motivation for change level of dysfunction and real-world
influences on his or her problems. The determination of treatment modes refers to
selection of the specific interventions which are matched to the uniqueness of the
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Case 5.10 The Golden Girls Sophia Petrillo ? 283
client and to his or her goals and clearly tied to a particular theoretical orientation
(Neukrug & Schwitzer 2006). Finally the clinician must establish how change will
be measured based upon a number of factors including client records and selfreport
of change in-session observations by the clinician clinician ratings results of
standardized evaluations such as the Beck Anxiety Inventory (Beck & Steer 1990) or
a family functioning questionnaire pre-post treatment comparisons and reports by
other treating professionals.
The four-step method discussed earlier can be seen in Figure 4.1 (p. 112) and is
outlined here for the case of Mrs. Petrillo followed by her specific treatment plan.
Step 1: Behavioral Definition of Problems. The first step in treatment planning is to
carefully review the case conceptualization paying particular attention to the results
of Step 2 (Thematic Groupings) Step 3 (Theoretical Inferences) and Step 4
(Narrowed Inferences). The identified clinical themes reflect the core areas of concern
and distress for the client while the theoretical and narrowed inferences offer
clinical speculation as to their origins. In the case of Mrs. Petrillo there are two
primary areas of concern. The first cognitive difficulties refers to her reduced
ability to plan menus follow a recipe and organize shopping and outings; her periodic
loss of memory of her daughters name those of her housemates and calling
for her deceased husband. The second behavioral and affective difficulties refers
to her irrational and erratic behavior and decisions that is wintertime gardening in
her nightgown and increased sarcasm beyond baseline. These symptoms and
stresses are consistent with the diagnosis of Mild Neurocognitive Disorder Due to
Possible Alzheimers Disease With Mild Behavioral Disturbance (Anonymous 2004
2006 2007; APA 2000a; Lykestos et al. 2006).
Step 2: Identify and Articulate Goals for Change. The second step is the selection
of achievable goals which is based upon a number of factors including the most
pressing or urgent behavioral emotional and interpersonal concerns and symptoms
as identified by the client and clinician the willingness and ability of the
client to work on those particular goals and the realistic (real-world) achievability
of those goals (Neukrug & Schwitzer 2006). At this stage of treatment planning it
is important to recognize that not all of the clients problems can be addressed at
once so we focus initially on those that cause the greatest distress and impairment.
New goals can be created as old ones are achieved. In the case of Mrs. Petrillo the
goals are divided into two prominent areas. The first cognitive difficulties
requires that we help Mrs. Petrillo to develop an understanding and acceptance of
her cognitive impairment to verbalize thoughts and feelings about these impairments
to develop alternative coping strategies to compensate for her developing
cognitive limitations and to provide psychoeducation and support for her immediate
family members. The second behavioral and affective difficulties requires
that we help Mrs. Petrillo understand the behavioral and affective symptoms that
accompany Alzheimers disease and develop coping strategies to recognize and
minimize their impact on her life.
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284 ? DIAGNOSIS AND TREATMENT PLANNING SKILLS
Step 3: Describe Therapeutic Intervention. This is perhaps the most critical step in
the treatment planning process because the clinician must now integrate information
from a number of sources including the case conceptualization the delineation
of the clients problems and goals and the treatment literature paying particular
attention to empirically supported treatment (EST) and evidence-based practice
(EBP). In essence the clinician must align his or her treatment approach with scientific
evidence from the fields of counseling and psychotherapy. Wampold (2001)
identifies two types of evidence-based counseling research: studies that demonstrate
absolute efficacy that is the fact that counseling and psychotherapy work
and those that demonstrate relative efficacy that is the fact that certain theoretical/
technical approaches work best for certain clients with particular problems
(Psychoanalysis Gestalt Therapy Cognitive Behavior Therapy Brief Solution-
Focused Therapy Cognitive Therapy Dialectical Behavior Therapy Person-Centered
Therapy Expressive/Creative Therapies Interpersonal Therapy and Feminist
Therapy); and when delivered through specific treatment modalities (individual
group and family counseling).
In the case of Mrs. Petrillo we have decided to use a two-pronged integrated
approach to therapy including Behavior Therapy and Cognitive Stimulation Therapy.
Behavior Therapy (Lazarus 2005 2008; Nye 1992; Wolpe 1990) is a highly empirical
approach to therapy that is based on the precepts of classical conditioning
social learning or modeling and operant conditioning (Neukrug 2011 p. 255).
Drawing heavily from learning theory it posits in a highly deterministic fashion that
all behavior whether adaptive or maladaptive is learned either through direct experience
or by observing the experiences of other people. These behaviors are learned
maintained and eliminated through the processes and schedules of reinforcement
punishment shaping chaining and extinction (Neukrug 2011). As noted earlier the
role of the therapist is to focus closely on describing and understanding what behaviors
(including affective responses) are occurring when and how they are occurring
what the antecedents and consequences (i.e. what leads to the behaviors and what
results from the behaviors) of the behaviors areand in turn what may be altered
or changed in the behavioral chain to improve these responses; in other words the
model focuses conceptually on the specific factors influencing and resulting from
current behaviors and methods of modifying these factors.
These procedures have been effectively applied in the cases of people struggling
with the symptoms of Alzheimers disease and related neurocognitive impairments
(Anonymous 2007; Ayalon et al. 2006; Livingston et al. 2005; Spector et al. 2000;
Spira & Edelstein 2006). Specific techniques for Mrs. Petrillo include functional
analysis of self-care skills charting/monitoring of successful implementation of selfcare
with verbal reinforcement shaping of appropriate problem-solving skills using
cue cards and hand-drawn pictures client self-monitoring of stress level and anger/
sarcasm caregiver education in behavioral management including shaping reinforcement
and extinction as well as support group for client and family regarding
neurocognitive decline.
Cognitive Stimulation Therapy (Anonymous 2004 2007; Livingston et al. 1996) is
predicated upon the notion that the cognitive impairments accompanying Alzheimers
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Case 5.10 The Golden Girls Sophia Petrillo ? 285
disease including memory reasoning planning and problem-solving are a function of
neurobiological deterioration. Cognitive stimulation in the form of cognitive exercises
(memory games puzzles arts-and-crafts) reminiscence (pictures songs cherished
objects) and creative-expressive and recreational activities (art music play) can and
have been proven effective in enhancing neurocognitive functioning (Livingston et al.
1996; Woods 2004; Woods et al. 1998) which in turn maintains and accentuates
daily living skills including self-care communication and organization. Specific techniques
for Mrs. Petrillo that are drawn from these approaches include reminiscence/
life review exercises comprised of music pictures and video outings to friends and
relatives creative/expressive exercises including art music and physical activity
Snoezelen (controlled multisensory) (Anonymous 2005; Livingston et al. 2005) activities
including visual auditory kinesthetic olfactory and somatosensory stimulation
relaxation including progressive muscle work and deep breathing.
Step 4: Provide Outcome Measures of Change. This last step in treatment planning
requires that we specify how change will be measured and indicate the extent to
which progress has been made toward realizing these goals (Neukrug & Schwitzer
2006). The counselor has considerable flexibility in this phase and may choose from
a number of objective domains (psychological tests and measures of self-esteem
depression psychosis interpersonal relationship anxiety etc.) quasi-objective measures
(pre-post clinician client and psychiatric ratings) and subjective ratings (client
self-report clinicians in-session observations). In Mrs. Petrillos case we have implemented
a number of these including ongoing measures on the Cohen-Mansfield
Agitation Inventory (Cohen-Mansfield 1991) client- and family-stated awareness of
the symptoms of Neurocognitive Disorder client and family report of attendance in
psychoeducational support group client and family report of attendance in
Cognitive Stimulation Therapy and clinician observation of clients communication
self-care emotional regulation and behavior control.
The completed treatment plan is now developed through which the counselor
Mrs. Petrillo and her family will begin their shared work of adjusting to the cognitive
emotional behavioral and interpersonal challenges of Neurocognitive Disorder.
The treatment plan appears here and is summarized in Table 5.10.
TREATMENT PLAN
Client: Mrs. Sophia Petrillo
Service Provider: Greater Miami Counseling Center
BEHAVIORAL DEFINITION OF PROBLEMS:
1. Cognitive difficultiesReduced ability to plan menus follow a recipe and organize
shopping and outings; periodic loss of memory of daughters name those of housemates
and calling for deceased husband
2. Behavioral and affective difficultiesIrrational and erratic behavior and decisions that
is wintertime gardening in her nightgown and increased sarcasm beyond baseline
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286 ? DIAGNOSIS AND TREATMENT PLANNING SKILLS
GOALS FOR CHANGE:
1. Cognitive difficulties
Develop an understanding and acceptance of her cognitive impairment
Develop alternative coping strategies to compensate for developing cognitive limitations
Verbalize thoughts and feelings about these impairments
Provide psychoeducation and support for immediate family members
2. Behavioral and affective difficulties
Understand the behavioral and affective symptoms that accompany Neurocognitive
Disorder Due to Alzheimers Disease
Develop coping strategies to recognize and minimize their impact
Provide psychoeducation and support for immediate family members
THERAPEUTIC INTERVENTIONS:
An ongoing course of individual and family Behavior and Cognitive Stimulation
Therapy supplemented with group psychoeducation and skill building
1. Cognitive difficulties
Functional analysis of self-care skills
Charting/monitoring of successful implementation of self-care with verbal reinforcement
Shaping of appropriate problem-solving skills using cue cards and hand-drawn pictures
Caregiver education in behavioral management including shaping reinforcement
and extinction
Support group for client and family regarding neurocognitive decline
Long-term family planning for alternative living arrangements as the level of impairment
progresses
2. Behavioral and affective difficulties
Reminiscence/life review exercises comprised of music pictures video and outings
to friends and relatives
Client self-monitoring of stress level and anger/sarcasm
Caregiver education in behavioral management including shaping reinforcement
and extinction
Creative/expressive exercises including art music and physical activity
Snoezelen (controlled multisensory) activities including visual auditory kinesthetic
olfactory and somatosensory stimulation
Relaxation including progressive muscle work and deep breathing
OUTCOME MEASURES OF CHANGE:
The development of client and family awareness of the symptoms and course of
Neurocognitive Disorder Due to Alzheimers Disease maintenance of optimal cognitive
and behavioral functioning and long-term care planning as measured by:
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Copyright 2015 by SAGE Publications Inc.
Case 5.10 The Golden Girls Sophia Petrillo ? 287
Ongoing measures on the Cohen-Mansfield Agitation Inventory
Client- and family-stated awareness of the symptoms of Alzheimers disease
Client and family report of attendance in psychoeducational support group
Client and family report of attendance in Cognitive Stimulation Therapy
Clinician observation of clients communication self-care emotional regulation and
behavior control
Diminished frequency of episodes of erratic behavior
Family report and clinician observation of reduced client sarcasm
Family report (through charting and clinician observation) of effective use of behavioral
strategies for clients improved coping skills
Family report of long-term care planning

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