Psychological Testing Instrument
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 NBC’s 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. Petrillo’s 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 s’mores—the hot dessert snack that combines
graham crackers, marshmallows, and melted chocolate—on 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 can’t
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. Petrillo’s 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 wasn’t going to
live somebody else’s life,” Mrs. Petrillo left her fiancé 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 Bloomingdale’s 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 mother’s shoulder
and who escorted her to one of the interviewing chairs. As she sat down, Mrs.
Petrillo pushed her daughter’s 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 mother’s most recent experiences, Mrs. Petrillo interrupted her and
announced, “Oh, now you’re 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, “I’ve lived
this long without any help from anyone, and I just need them to know that I’m 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
I’d 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 I’m nuts and want to lock me in this crazy joint … no way José.” 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 Alzheimer’s 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 daughter’s 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. Petrillo’s 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 person’s 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. Alzheimer’s
Disease, Traumatic Brain Injury, HIV infection, Parkinson’s Disease, Huntington’s
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 Alzheimer’s 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.
Petrillo’s 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 Alzheimer’s Disease. Mrs. Petrillo’s 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 counselor’s special
attention (Schlossberg, 1995). In the case of Neurocognitive Disorder Due to
Alzheimer’s 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. Petrillo’s 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. Petrillo’s case, there is no lifelong
history at all of Schizophrenia. Alternatively, Major Depressive Disorder may
feature impairment in memory, concentration, and thinking—and clinicians are
alerted that depressive disorders may be difficult to differentiate from cognitive
impairment in older adults (Chapman & Perry, 2008). However, in Mrs. Petrillo’s
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 Alzheimer’s Disease.
To finish the diagnosis, Mrs. Petrillo’s 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. Petrillo’s onset of concerns.
Case Conceptualization
During Mrs. Petrillo’s 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. Petrillo’s 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 Alzheimer’s Disease, With Mild Behavioral
Disturbance. A case conceptualization next was developed. Whereas the purpose of
diagnostic impressions is to describe the client’s concerns, the goal of case conceptualization
is to better understand and clinically explain the person’s 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
client’s 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. Petrillo’s 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. Petrillo’s 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 counselor’s 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. Petrillo’s
prominent signals of the early onset of Alzheimer’s-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 adjustment—all 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. Petrillo’s clinician believed that, in her case, the
Clinical Targets Approach was the most effective bridge between Mrs. Petrillo’s 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 Alzheimer’s 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. Petrillo’s 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. Petrillo’s
issues as they are seen in Steps 1 and 2.
Step 3: Theoretical Inferences. At Step 3, concepts from the counselor’s theoretical
integration of two approaches—Behavior Therapy and Cognitive Stimulation—are
applied to the factors causing, and the mechanisms maintaining, Mrs. Petrillo’s
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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 daughter’s 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. Petrillo’s 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. Petrillo’s 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 Petrillo’s 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. Petrillo’s current needs (Neukrug & Schwitzer, 2006; Schwitzer, 1996, 1997).
First, Behavior Therapy was applied primarily to clinically thinking through Mrs.
Petrillo’s 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 are—and 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 Alzheimer’s 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 person’s 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. Petrillo’s 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. Petrillo’s 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 rates—and 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. Petrillo’s 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 clinician’s 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. Petrillo’s 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. Petrillo’s 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. Petrillo’s
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. Petrillo’s 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. Petrillo’s 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.
Petrillo’s 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 client’s life. In essence, the treatment
plan is a road map “for reducing or eliminating disruptive symptoms that are impeding
the client’s 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 client’s concerns into a hierarchy of urgency that also takes
into account the client’s 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 daughter’s 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 Alzheimer’s 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 client’s 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 Alzheimer’s 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 client’s 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 are—and 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 Alzheimer’s 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 Alzheimer’s
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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, clinician’s in-session observations). In Mrs. Petrillo’s 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 client’s 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 difficulties—Reduced ability to plan menus, follow a recipe, and organize
shopping and outings; periodic loss of memory of daughter’s name, those of housemates,
and calling for deceased husband
2. Behavioral and affective difficulties—Irrational 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 Alzheimer’s 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 Alzheimer’s Disease, maintenance of optimal cognitive
and behavioral functioning, and long-term care planning as measured by:
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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 Alzheimer’s disease
•• Client and family report of attendance in psychoeducational support group
•• Client and family report of attendance in Cognitive Stimulation Therapy
•• Clinician observation of client’s 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 client’s improved coping skills
•• Family report of long-term care planning