Written Assignment 2: Collaborative Care Plan Assessment

Purpose

In this assignment, you are required to demonstrate your skills in conducting a comprehensive mental health assessment of a consumer. You are required to demonstrate the importance of incorporating both a trauma-informed and recovery-oriented approach to reflect the consumer’s lived experience in your mental health assessment.

Description

Choose a suitable setting, such as an inpatient unit, community centre, emergency department, or another acute care setting. Remember to keep all information anonymous by using a pseudonym for the person you discuss. If you’re unable to find someone in these settings, you may base this assignment on a client you are currently working with who has known mental health concerns.

This assessment requires you to provide the following:
Part 1: A succinct yet comprehensive mental health assessment utilising a trauma-informed, recovery-oriented approach and biopsychosocial approach. This assessment must include a comprehensive history, and assessment of physical health, psychosocial health, history of trauma, vulnerabilities and strengths.

There must be evidence of a collaborative approach that is consumer-focused, and recovery-orientated and describes engagement and the therapeutic relationship. It must clearly articulate the consumers’ goals, wants and views of their current situation and future plans.

Part 2: Provide a formulation of the problems (arising from the mental health assessment) including a summary of symptoms of mental illness, the consumer’s perspective and context.
While this is a clinically based assignment, your assignment must be supported with contemporary high-quality references (avoid reliance on health policy documents as your sole source) and demonstrate your capacity for sound clinical reasoning.

Part 3: Develop a detailed, recovery-oriented, and trauma-informed treatment plan. This plan should include practical strategies aimed at improving consumer engagement and satisfaction while addressing their unique challenges.

Assessment Requirements Summary

This assignment focuses on conducting a comprehensive mental health assessment of a consumer, incorporating trauma-informed, recovery-oriented, and biopsychosocial approaches. The key objectives include:

1. Mental Health Assessment (Part 1):

   • Gather a detailed history including physical, psychosocial, and trauma-related factors.

   • Identify consumer vulnerabilities, strengths, and current mental health status.

   • Demonstrate a collaborative and consumer-focused approach, articulating the consumer’s goals, needs, and perceptions of their current situation and future plans.

2. Problem Formulation (Part 2):

   • Summarise presenting mental health symptoms.

   • Contextualise symptoms with the consumer’s lived experience and perspective.

   • Identify key problems and challenges based on clinical reasoning.

3. Recovery-Oriented and Trauma-Informed Treatment Plan (Part 3):

   • Develop practical strategies to improve engagement and satisfaction.

   • Include interventions tailored to the consumer’s needs, strengths, and recovery goals.

   • Demonstrate integration of trauma-informed principles and recovery-oriented practices.

Learning Objectives:

• Apply trauma-informed care and recovery-oriented principles.

• Conduct a thorough biopsychosocial assessment.

• Develop individualized treatment plans based on clinical reasoning.

• Demonstrate effective consumer engagement and therapeutic relationship skills.

• Critically integrate contemporary research into clinical practice.

Approach Guided by the Academic Mentor

Step 1: Understanding Assessment Expectations

• The mentor first outlined the scope: assessment must be holistic, trauma-informed, and recovery-oriented, reflecting the consumer’s lived experience.

• Emphasis was placed on ethical considerations, including anonymity and use of pseudonyms.

Step 2: Conducting the Mental Health Assessment (Part 1)

• The student was guided to collect comprehensive information:

  • Physical health: chronic conditions, medications, lifestyle factors.

  • Psychosocial health: family, social networks, education, employment.

  • Trauma history: past abuse, neglect, or adverse life events.

  • Strengths and vulnerabilities: coping strategies, support systems, resilience factors.

• Mentorship included demonstrating engagement techniques: active listening, empathetic questioning, and validating the consumer’s perspective.

• Emphasis was placed on documenting consumer goals and future aspirations as part of recovery-oriented care.

Step 3: Formulating the Problem (Part 2)

• The student was taught to synthesise assessment findings into a clinical formulation:

  • Identify core symptoms of mental illness.

  • Consider contributing psychosocial and environmental factors.

  • Integrate the consumer’s perspective and lived experience to contextualise the issues.

• The mentor guided the student in linking assessment data to clinical reasoning, ensuring a clear problem summary.

Step 4: Developing the Treatment Plan (Part 3)

• The mentor instructed the student to design a practical, trauma-informed, and recovery-focused plan:

  • Include interventions for symptom management, engagement, and skill-building.

  • Ensure culturally sensitive and personalised strategies.

  • Specify monitoring and follow-up mechanisms, including collaboration with other health professionals.

• Emphasis was placed on consumer-centred strategies such as motivational interviewing, psychoeducation, and goal-oriented support.

Step 5: Integration and Documentation

• The student was guided to compile the assessment, problem formulation, and treatment plan into a coherent, professional report.

• Documentation highlighted the therapeutic relationship, consumer collaboration, and rationale for interventions.

• Mentor encouraged inclusion of current, high-quality references to support clinical reasoning.

Outcome and Learning Achievements

• The final report provided a holistic mental health assessment, integrating physical, psychosocial, and trauma-related factors.

• Problems were formulated with clear articulation of symptoms and context, incorporating the consumer’s perspective.

• A recovery-oriented and trauma-informed treatment plan was developed with practical interventions and strategies to enhance engagement and satisfaction.

• Learning objectives achieved included:

  • Demonstrating trauma-informed and recovery-oriented care.

  • Applying biopsychosocial assessment skills.

  • Developing consumer-focused treatment strategies.

  • Using evidence-based references to support clinical reasoning.

  • Enhancing therapeutic communication and professional documentation skills.

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