NORTHLAND COMMUNITY AND TECHNICAL COLLEGE

OCCUPATIONAL THERAPY ASSISTANT PROGRAM

Case Study Treatment Plan
George: Bipolar Disorder

Case Study – Complete the following Chart

All information is included, detailed, organized, professional, no errors/appropriate grammar (6 pts.)
Name, Age and Identifying George, 37 years old separated, black male, father of two children, diagnosis of bipolar disorder with a secondary diagnosis of
Information: (Including anything cocaine and alcohol abuse
pertaining to client’s culture/beliefs)

Description of Diagnosis: State what it A brain disorder that causes unusual shifts in moods, energy and activity levels and an inability to attend to day to day
is and describe the diagnosis. tasks

Pertinent information in treatment of He is in a manic state

client and the specific Diagnosis:
Identify anything that needs to be
considered or taken into account with
this diagnosis. Any Precautions,
concerns, etc. that need to be followed.

Cultural Context Black male, hard-working and motivated to succeed, soccer dad, separated
Anything that needs to be considered
due to patients culture/beliefs?
Personal context 37 year old male
Temporal Context Middle adulthood
Virtual context N/A
Environments -Physical Was living with his family, but is not welcome back unless he is stable on medications
Environments-Social Is married but wife says that she may not welcome him home at all, two children
Type of Setting: Inpatient treatment facility

Anticipated D/C setting: 7-10 days

Frequency/Duration of OT: 2-3x/day

Client’s assets: Has a master’s degree, has his own business, motivated and has established goals, has raised money for charity in the past,
no physical limitations

Psychosocial Treatment Plan

Purpose: __/8

1. Identify the Primary Frame of Reference behind this treatment plan and your rationale for choosing it.
(1 pts)
Person Environment Outcome (PEO)- try to balance person and environment for a good
outcome.
2. Purpose is Appropriate for goal (s). Write a brief description of why this treatment plan is needed,
discuss the client’s problems that make you feel this goal is necessary. (2 pts.)
This treatment plan is needed because patient has diffi culty concentration and paying
attention to tasks given. Patient social participation skills are impaired due to lack of eye
contact for more than a few seconds and tangential speech.
3. Go through the OTPF and identify the Occupations, Client Factors, Performance Skills, and Performance
Patterns that are a weakness and are a reason for this treatment plan. Describe why the client has a
defi cit in the diff erent areas you choose. (4 pts.)
 Occupations:
 IADLs- communication management- has a hard time communicating with others; fi nancial
management- goes on shopping sprees during manic state
 Work- is currently unable to hold a job
 Social Participation- unable to make eye contact, pay attention, concentrate, and inhibits tangential
speech.
 Sleep/Rest: lack of sleep during manic state
 Client Factors:
 Attention- has diffi culty paying attention- has an attention span of under 1 minute
 Concentration- has diffi culty concentrating on conversations
 Temperament and personality: Impulse control- shouts and yells answers to questions; has a
tendency to pick pieces of lint off chair, kicks the table leg, and twist phone cord.
 Performance Skills:
 Attends- has a hard time attending to a task for more than 1 minute
 Looks- has diffi culty maintaining eye contact for more than 5 seconds
 Regulates- has diffi culty controlling his impulse control
 Concludes/Disengages- doesn’t terminate conversations, tangential speech
 Matches Language- shouts/yells during conversations
 Performance Patterns:
 Roles- roles of father, entrepreneur, husband, and friend are inhibited due to behavior while in
manic state.
 Routines- unable to follow appropriate daily tasks due to attention and concentration during manic
 behavior.
4. Discuss the Context and Environment as it relates to this treatment and goal. (1 pt.)
 Context :
 Personal- a 37 year old former entrepreneur and father; has a master’s degree in marketing and
public relations; participates in charity events
 Environments :
 Social- relationship with friends, wife, kids, co-workers and employees are inhibited due to
behavior in manic state.

Total Points: All above must be present and appropriate, written professionally, minimal to no
grammar/writing errors.
Identify the top 2 problems and Create appropriate goals for OT Treatment (STG/LTG for each area). ___3
Develop a GOAL using RUMBA:
Relevant , Understandable, Measureable, Behavioral, Achievable
Total Points: Goal(s) must meet the above requirements and be appropriate for individual, written
professionally, with minimal to no grammar/writing errors.

Problem #1: (.50 pt.) LTG#1(.50 pt.) Client will concentrate on a task for 15 minutes at a time
Difficulty with concentration and attention within 10 days to improve his ability to work.
STG#1 (.50 pt.) Client will concentrate on a task for 5 minutes at a time
within 3 days to improve his ability to work.
Intervention 1a. Charades
Intervention 1b. Puzzles
Intervention 1c. Card Games
Problem #2 (.50 pt.) LTG#2(.50 pt.) Client will look, turn towards, and match language during
Social Interaction social interaction in 10 days.
STG#2(.50 pt.) Client will maintain appropriate eye contact for 1 minute in 3
days.
Intervention 1a. Name Recall- improves attention, concentration,
and social interaction skills. Each person introduces their name to
the group and shares personal information about self. Individuals
in the group need to remember all of the individual’s names and
personal information they shared.
Intervention 1b. Headbandz game
Intervention 1c. The Ungame- helps improve social interaction and
 express emotions
Treatment: __/15

1. Explain how the treatment interventions are consistent with the Frame of Reference. (2 pts)
2. Identify The Intervention Approaches for the interventions and your rationale for choosing these. (1
pts)
3. Describe each individual activity and the amount of time needed for each activity. Be sure you describe
exactly what will be taking place in the activity. (1 pt.)
a. For each activity please list:
i. Relevance and Importance to the client (1 pt.)
ii. Objects used and their properties (1 pt.)
iii. Space Demands (1 pt.)
iv. Social Demands (1 pt.)
v. Sequencing and Timing (1 pt.)
vi. Required Actions and Performance Skills
1. For Each individual activity list the specifi c Occupations, Client Factors, Performance
Skills, and Performance Patterns you are addressing (these must be listed in the
Purpose section) and how you are addressing them. (4 pts.)
vii. List any Context and Environmental Factors that are associated with the activity. (1 pt.)
viii. List the Type of Intervention this activity is. (1 pt.)

Total Points: All above must be present and appropriate, written professionally, minimal to no
grammar/writing errors.

Treatment Session: 45 minutes/3 units

Frame of Reference: Person-Environment-Outcome: George needs to balance his environment and personal
context of behavior in order to achieve and maintain a good outcome of life and to improve occupations.

Intervention Approaches: Establish/Restore- Want to work with George to restore his social interaction
skills.
 Name Recall- improves attention, concentration, and social interaction skills. Each person
introduces their name to the group and shares personal information about self. Individuals
in the group need to remember all of the individual’s names and personal information they
shared. (15 minutes/1 unit)
 Relevance and Importance to Client: important to client because it helps improve the client’s
concentration and attention skills which will help improve the client’s social interaction skills.
 Objects used and their properties : N/A- it is an oral activity so only need to speak
 Space Demands: Clients are seated in chairs in a circle. Room needs to be large enough to
accommodate all members of the group comfortably.
 Social Demands: Clients need to be able to interact and attend to all group members.
 Sequencing and Timing:
o Clients, one by one, state there name and one personal fact. 12 minutes
o Group members should pay attention to every group members name and
personal fact prior to individuals turn
o When It is client’s turn, client will state all individual’s names and personal
facts and then say their own name and personal fact.
o Everyone in group will go around and say their names and personal fact until
there is one person left in the game.
o If client forgets someone’s name or personal fact, then they will be out.

 Occupations: Social Participation- unable to make eye contact, pay attention, concentrate, and inhibits
tangential speech
 Client Factors:
 Attention- client needs to pay attention to other group member’s names and personal facts. If client
does not pay attention, then he will not remember other group member’s information.
 Concentration- Client needs to concentrate on other group member’s information in order to remember
what was said.
 Performance Skills:
 Attends- client needs to attend to task for entire activity in order to be able to recall other group
member’s names and personal fact.
 Looks- client needs to look at other group members while they are speaking in order to know what
group member said their name and personal fact.
 Performance Patterns:
 Routines- activity will improve client’s concentration and attention which will improve his daily tasks.
 Context : N/A
 Environment:
 Social - will improve social environment because client will be able to pay attention and concentrate
while others are speaking to him.
 Intervention Type: Activities- Name Recall is an activity to help improve attention, concentration, and
social interaction skills to help improve client’s social participation skills.
 Headbanz (30 minutes/2 units)
ix. Relevance and Importance to the client (1 pt .) – Important to client because it will help the
client with his social interaction skills that are needed and expected by society
 x. Objects used and their properties (1 pt.)— Headbandz Game (cards, headbands, question
card), chairs
xi. Space Demands (1 pt.) – Clients are seated in chairs in a circle. Room needs to be large
enough to accommodate all members of the group comfortably.
xii. Social Demands (1 pt.) – Clients need to be able to interact and attend to all group
members and show impulse control
xiii. Sequencing and Timing (1 pt.)— 30 minutes
a. 5 minutes to explain the game, how to put on the headbands, and pick cards
b. 15 minutes to play the game with the group
c. 10 minutes to take down game, count cards and discuss how everyone felt the
game went
xiv. Required Actions and Performance Skills

Occupations: Social Participation- unable to make eye contact, pay attention, concentrate, and inhibits
tangential speech
 Client Factors:
 Attention- Client has to pay attention to questions being asked by others as well as answers that he
has received
 Concentration- has to be able to concentrate on one card at a time
 Temperament and personality: Impulse control- needs to be able to control verbal outbursts

Performance Skills:
 Attends: He will attend to activity for 25 minutes
 Looks: Client will look at other participants while speaking and communicating
 Matches Language: Client will use appropriate tone while communicating with other group
members

Performance Patterns: N/A

xv. List any Context and Environmental Factors that are associated with the activity. (1 pt .)—
Physical: Calming environment with minimal distractions
xvi. List the Type of Intervention this activity is. (1 pt .)-- Activity: activity to help engage
individual to turn towards others, match language, and improve impulse control during
social participation activities.
Adaptation: Select one activity identified in the interventions and explain how you would adapt it to compensate for the __/2.5 pts.
client’s inability to perform a task.
Adapt the environment by limiting distractions in the room and having everyone sit in a circle. Can also adapt the game of
Headbanz by providing a list of questions to ask to identify what the individual’s headband is.
 Grading: Select one activity identified in the intervention and describe how you would grade it throughout the course of __/2.5 pts.
treatment.
Name Recall: Client can first began with only a couple other members for the Name Recall and eventually grade up to a
group of 5-6 people to concentrate and pay attention to other’s names and personal facts.
Headbanz: client can first have two minutes to try to guess the item on her headbanz and eventually grade up to only one
minute. Client can first have an easy object to guess and eventually grade up to a more difficult object to guess on own
headband.
Culturally Relevant: Provide your rationale for how this treatment plan is culturally relevant (1.5 pt), reflective of current ___/3
occupational therapy practice (1.5 pt), and based on available evidence (1.5 pt.).
It is culturally relevant for individual’s to look at others while they are speaking, to control tangential speech, and to be able
to hold a job for a long period of time. This treatment is culturally relevant because it encourage the individual to control his
speech and helps improve looking skills while speaking to others.

4 pts. Evidence Based Practice: ___/4

Provide the APA Citation (1 pt.) for 1 EBP article that you feel provides an appropriate treatment method/Activity for this
diagnosis, describe the treatment method (1 pt.) and why you chose it (1 pt.) and how you used it in your treatment (1 pt.).
Make sure you discuss why this treatment method would help the patient/how it will be used in the treatment you are
providing.

Social Dysfunction in Bipolar Disorder: pilot study.

Castanho de Almeida Rocca, C., Britto de Macedo-Soares, M., Gorenstein, C., Sayuri Tamada, R., Kluger Issler, C., Silva Dias, R., & ... Lafer, B. (2008). Social
dysfunction in bipolar disorder: pilot study. Australian & New Zealand Journal Of Psychiatry, 42(8), 686-692. doi:10.1080/00048670802203426
This article talks about how individual’s with bipolar disorder present an impairment in the capability to cope with social
situations and to these individuals tend to be more cautious in making social contact and feel uncomfortable when they need
to interact in a direct way in interpersonal relationships. We chose this article because it talks about how individuals with
bipolar disorder feel when they approach social situations, and how the individuals feel while approaching social situations
does not correlate with the duration of the illness, number of hospitalizations, number of manic and depressive episodes, or
psychotic symptoms. This will be used in treatment by knowing how individuals with bipolar disorder feel when approaching
social situations and so health professionals know how to adapt and grade different social activities to meet the basic needs
of the individual. This will help the patient so health professionals know how to approach individuals with bipolar disorder and
can adapt and grade social situations and activities to meet the needs of the client.
3 pts. Health Professionals: __/3
Identify the Health Professionals that would be important to collaborate with in regards to this patient (more than 2) (1.5 pts.)
and discuss why (1.5 pts).

Psychiatrist- can help individual when facing emotional needs or when individual is faced with a manic state.

Nursing- to help make sure George receives the proper medication that he needs during his hospital stay
 Recreational Therapist- help restore George’s level of functioning and independence in social participation activities

Social Worker- Make sure all his needs are being met
2 pts. Referral to specialists: __/2
Identify when you would recommend to the OT the need for additional evaluation and referral to specialists (inter-
professional and intra-professional) for consultation and intervention.
Would refer client for additional evaluation when client’s needs and goals have no progress and are not being met, or are
already met.

Total Points: __/49

________________________________________________

***Write a DAP Note Based on one treatment session selected from the intervention plan above. (Knowing that you can
contribute to the DAP Note, and the OTR/L needs to sign off on the Note and document collaboration was completed)

5 pts. = All information is included, detailed, organized, professional, no errors/appropriate grammar. 1 pt. for each section, 1 point for
signature.

Based off the one session of treatment. Information in appropriate sections. Signature included.

DAP Note:
D: Client stated “I am looking forward to group today”. Client would fidget and tap his feet once activities began and would approach
conversations with tangential speech. Client began to get upset and discontinued to pay attention to game when asked to not use
inappropriate language during group.

A: Client appeared calm and ready to engage in social participation activity at the beginning of group. Client’s inability to pay attention, use
impulse control, regulate emotions, and match language interfered with client’s ability to complete group activities.

P: Continue OT treatment 3x/week for 6 weeks.

Would recommend discharge if goals have been met, or when there has been no progress made towards goals.

***Write a Discharge Summary (knowing that you could contribute to the D/C plan, and the OTR/L needs to sign off on the Plan
and document collaboration was completed)
Discharge Summary:
1. Client information: George, 37 years old, Black male, Bipolar disorder with substance abuse
2. Summary of intervention process:
Initial service: 2/10/16
Final Service: 2/18/16
32 Sessions
Interventions Used- Addressed social participation and concentrations/attention
Progress: Client is able to control verbal impulses and has shown an increase in all aspects of social participation/interaction. Client is
able to attend to task for 20
Minutes without getting distracted.
Outcomes: Client participation in role competence, participation in social activities, and quality of life will improve when goals are not
met or will decrease if goals are not being met or if there is no progress shown during treatment.
3. Recommendations—Client should work with a psychiatrist to manage appropriate medications. Client is recommended couples therapy
with his wife to improve family interaction and quality of life in the home.

Outcomes: Client’s participation role competence, participation in social activities, and quality of life will improve when goals are met or will decrease if goals are not being met or
if there is no progress shown during treatment.

Amanda Edwardson/OTAS/2-29-16
Sydney Larson/OTAS/2-29-16
Erika Bachmeier/OTAS/2-29-16
Cheyanne Davis/OTAS/2-29-16
Rita Coleman/OTAS/2-29-16

Total Points: _______/ 65