CNS 770: Classification of Mental Health Disorders provided my first opportunity to begin drafting sample treatment plans. The document below (Assignment 4.1) shows that I was able to learn a new way of gathering and synthesizing important information about the client. It also shows that I am committed to staying up-to-date on the best practices for documentation. This knowledge of how to identify what is most vital and how to document it will allow me to serve my clients more effectively. Click here to download a PDF version.
Treatment Plan Example
Client Name: Crystal Smith Primary Concerns Crystal Smith has been experiencing symptoms which have negatively affected her family and social life, along with her physical health for over eight months. Her husband has brought her to counseling, as he is concerned with her well-being. The client has met with a physiatrist in the past, but was not compliant with the doctor’s suggestions and quickly left treatment. However, Ms. Smith did have a positive experience with a school counselor as a child. Some goals of treatment are for the client to regain the energy to be present in her young children’s lives and to improve her relationship with her husband.
Treatment Plan
Diagnosis. Ms. Smith clearly meets the criteria for Major Depressive Disorder [296.22]. This is evidenced by her symptoms of insomnia (early morning waking), fatigue, guilt, agitation, significant weight loss (13 pounds), social retreat, and tearfulness. Since the client reports being in good health and not using alcohol or other substances, these depressive symptoms cannot be better explained by another disorder. It may also be appropriate to specify “with melancholic features” as Ms. Smith has experienced “loss of pleasure in all, or almost all activities” along with “early-morning awakening” and “significant weight loss” (APA, p. 185). The client also expressed feelings of guilt, although the extent of these feelings is unclear. One major concern is the client’s repeated mention of “mistrust” in family members. While this suggests a possible paranoid personality disorder [301.0], it will need to be further explored to see if Ms. Smith suspects malevolence or if she is simply anxious and concerned over her children’s safety. Clarifying this concern will be integrated into the treatment plan.
Objective. The goals of treatment are to help Ms. Smith return to her pre-depression level of functioning and eliminate unpleasant symptoms. As the client’s main concerns were her relationships with her husband and in-laws, it will be a primary goal to reduce interpersonal conflict, improve communication, and explore her feelings of mistrust toward others. The client will be taught coping skills to manage depressive symptoms. The client will also learn to identify warning signs and utilize healthy habits that may aid in the prevention of a future major depressive episode.
Assessments. As the client did express some suicidal thoughts by saying she “would be better off dead,” the first assessment that should be completed is a suicide assessment. While she asserts that she would never go through with it, an assessment would allow the clinicians to gain a better understanding of whether she had a plan or means to end her life. To assess the client’s depression, the Beck Depression Inventory and Hamilton Rating Scale should also be administered (Reichenberg & Seligman, 2016). To gain a better understanding of the client’s background, the clinician should ask about family history of mental illness, personal history of trauma, and what was occurring in the client’s life during the onset of the depressive symptoms.
Additionally, the client should be referred for a medical examination with a primary care physician to rule out any issues such as thyroid irregularity that may be contributing to her symptoms. It might also be useful to assess for some psychotic symptoms based on her “mistrust.” Due to her resistance to psychiatry and medicine noncompliance in the past, it would be best to build rapport before referring the client for another psychiatric evaluation.
Clinician characteristics. Since the client is hesitant of the therapeutic process, she would benefit from an empathetic and culturally-competent therapist. A strong rapport should be built and Ms. Smith’s boundaries should not be crossed too early in the therapeutic process. Also because of Ms. Smith’s resistance, the counselor should not be overly directive and should maintain a disposition of non-judgement.
Location, timing, and number of people. The client will be treated with outpatient services at minimum once per week until symptoms have significantly improved. Couples therapy will also be conducted to help Mr. and Mrs. Smith improve their communication and process the stress of the last 10 months. Individual and couple sessions will be 50 minutes long. The initial timeline will be a goal of 15 to 20 sessions and progress will be assessed around session 10 so the treatment length can be adjusted accordingly.
Group therapy is not likely to be a fitting environment for the client as she has expressed mistrust of others and a dislike for people “getting into her business.” Reichenberg & Seligman (2016) explain that the therapeutic setting should depend of the clients “danger to themselves” and “effectiveness of prior treatment” (p. 45). Based on this rationale, if outpatient therapy proves to be unhelpful for Ms. Smith (as did her last attempt) or her suicidal ideation worsens, it may be appropriate for the client to be placed in a half-day partial-hospitalization program (PHP). This could be completed while the client’s children are in school or day-care, providing a higher level of care without separating her from her family.
Interventions. The client will be given psychoeducation related to depression and Cognitive Behavioral Therapy (CBT) techniques. She will also be guided through mindfulness techniques based on the tenants of Dialectical Behavioral Therapy (DBT). The client will also be encouraged to maintain a journal to track thoughts and moods. Additionally, motivational interviewing (MI) will be used to encourage the client to decide to change during the beginning stage of treatment (Reichenberg & Seligman, 2016, p. 33). An approach based on Acceptance and Commitment Therapy (ACT) will be utilized in sessions with Mr. and Mrs. Smith as this approach has been shown by evidence to help clients with depression and marital conflict (Reichenberg & Seligman, 2016, p. 52).
Emphasis. The emphasis of treatment will be to give the client tools to manage and overcome her depression. Specifically, the client’s main concerns of discord with her husband and mistrust of her in-laws will be addressed throughout treatment. DBT and CBT skills such as radical acceptance and confronting cognitive distortions through journaling will be taught to the client so she can continue this work beyond the walls of therapy. The focus of the sessions will be on present symptoms and stressors. The approach will be a mixed approach that begins more “evocatively” but eventually becomes more “directive” as the counselor begins to assign homework (Reichenberg & Seligman, 2016, p. 58). The aim of treatment is to provide “supportive psychotherapy” which “instills hope” and allows the client to “continue with skills of daily living” (Reichenberg & Seligman, 2016, p. 59).
Medications and adjunct services. The client will be encouraged to integrate regular exercise into her routine, even if it is something gentle like a walk or yoga. This will likely help to boost her energy level and mood. A medication may also be prescribed by her primary care physician to help Ms. Smith establish consistent sleep patterns. After rapport has been established, a referral to a culturally-competent psychiatrist will be made. However, the client will need to first understand the importance of medication compliance and be willing to commit to treatment before medication can be prescribed. Specifically, it will need to be explained that most anti-depressants do not begin to take affect for several weeks and that she should not discontinue the medication during that time. Finally, as spirituality seems to be an integral part of the client’s life, she will be encouraged to resume meeting with her pastor and attending either a weekly worship service or a small group.
Prognosis. The client’s prognosis is good since this appears to be her only instance of a major depressive episode. However, the outcomes of treatment are largely dependent of “the client’s motivation to make positive changes” and “the presence of supportive interpersonal relationships” (Reichenberg & Seligman, 2016, p. 73, 372). This means that creating better communication between the client and her family (husband and in-laws) will be integral to her recovery.
Treatment Plan Rationale The outlined treatment plan takes a holistic approach to support Crystal Smith in reducing depressive symptoms and preventing a relapse of symptoms in the future. An eclectic theoretical approach will allow the client’s counselor to use the most beneficial aspects of Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), and Dialectical Behavioral Therapy (DBT) in order to provide Ms. Smith with a personalized treatment plan. The counselor will respect Ms. Smith’s boundaries and resistance to treatment, while gently becoming more directive as the therapeutic relationship strengthens. The client’s progress and symptom reduction will be assessed in an on-going matter so the treatment plan can be adjusted to be as helpful as possible. For that reason, this plan is meant to be a guide, but also to be flexible based on the client’s response and receptivity. As the symptom of “mistrust” is explored, there may be room for a differential or additional diagnosis which may lead to a higher level of care or an altered treatment plan. Additionally, the client’s suicidality will continually be assessed for her safety. While it is likely that the most success would come from the combination of therapy and medication, the client’s wishes should be respected if she declines medication.
References: American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders - DSM-5TM (5th edition). American Psychiatric Publishing, Arlington, VA.
Reichenberg, L.W. & Seligman, L., (2016). Selecting Effective Treatments – A comprehensive, systematic guide to treating mental disorders (5th edition). Hoboken, NJ: John Wiley & Sons, Inc.