Treatment Plan Completion and Essay

DSM Diagnosis – Persistent Depressive Disorder (Dysthymia) 300.4 (F34.1)

ICD Diagnosis - F34.1 Dysthymia

Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years. Presence, while depressed, of two (or more) of the following: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, and feelings of hopelessness.

A chronic depression of mood balance between individual phases of mild depression and intervening periods of comparative normality is very variable. Sufferers usually have periods of days or weeks when they describe themselves as well, but most of the time (often for months at a time) they feel tired and depressed; everything is an effort, and nothing is enjoyed.

Problem/Symptom: The depression appears to be derived from struggling to make friends, difficulty completing college assignments, and poor self-esteem.

Problem/Symptom: Sleep badly and feel inadequate but are usually able to cope with the basic demands of everyday life.

DSM Diagnosis - Separation Anxiety Disorder 309.21 (F93.0)

ICD Diagnosis - F93.0 Separation Anxiety Disorder of Childhood

Developmentally inappropriate and excessive anxiety concerning separation from those to whom the individual is attached. Recurrent excessive distress when experiencing separation from home or from major attachment figures. Persistent and excessive reluctance about being alone or without major attachment figures at home.

Excessive anxiety concerning separation from those individuals to whom the child is attached (usually parents or other family members). persistent inappropriate fear of being alone, or otherwise without the major attachment figure. It is differentiated from normal separation anxiety when it is of such severity that is statistically unusual (including an abnormal persistence beyond the usual age period) and when it is associated with significant problems in social functioning.

Problem/Symptoms: Family separation approximately two hours away. Eliza struggles to make friends. She appears to miss her high school friends who have gone to college somewhere else or doing other things.

Problem/Symptoms: Eliza seems to have excessive anxiety concerning separation from those individuals to whom the she is attached (usually parents or friends).

DSM Diagnosis – Insomnia Disorder 307.42 (F51.01)

ICD Diagnosis - F51.0 Nonorganic Insomnia

Dissatisfaction with sleep quantity or quality. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. The sleep difficulty is present for at least 3 months. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other critical areas of functioning.

Insomnia is a condition of unsatisfactory quantity and/or quality of sleep, which persists for a considerable period. Difficulty falling asleep is the most prevalent complaint, followed by difficulty staying asleep and early final wakening. Often cope with tension by taking medication or alcohol. In the morning, frequently report feeling physically and mentally tired. During the day, they characteristically feel depressed, worried, tense, irritable, and preoccupied with themselves.

Problem/Symptoms: During the Level 1 cross-cutting symptom measure of problems Eliza identified lack of sleep affected her sleep quality.

Problem/Symptoms: Feeling worried, tense, or depressed at bedtime, as many thoughts are racing through Eliza’s mind.

DSM Diagnosis - Alcohol Use Disorder 303.90 (F10.20)

ICD Diagnosis - F10 - Mental and Behavioral Disorders Due to Use of Alcohol

Alcohol is often taken in larger amounts or over a longer period than was intended. Recurrent alcohol use resulting in a failure to fulfill significant role obligations at work, school, or home. The use of alcohol occurs despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

A condition that follows the administration of a psychoactive substance resulting in disturbances in level of consciousness, cognition, perception, affect or behavior, or other psycho-physiological functions and responses.

Problem/Symptoms: Eliza drinks with her college friends and began consuming alcohol in high school to please her high school friends.

Problem/Symptoms: The alcohol drinking manifests into poor self-esteem, low energy, and lack of sleep. The disturbance impacts Eliza perception and affects her social behavior.

Goals / Objectives:

Interventions:

Frequency:

□ Mood Stabilization

Goal:

· Maintain stability of mood or Improve overall mood

Objectives:

· Eliza will learn three ways to manage her frustration in an encouraging way

· Eliza will report felling more positive about herself and her abilities

· Eliza will report feeling a happier mood, five out of seven days

· Eliza will get through a week without becoming negative for more than 5 minutes

□ Psychotropic Medication Referral & Consultation

□ Journaling - Journaling will prove a safe, personal outlet to for the client to express things the client cares to address.

□ Cognitive Behavior Therapy

□ Skill Training

□ Emotion Recognition & Regulation Techniques - Learn to respond to life experiences of ongoing demands on emotions in a way consistent with socially respectable ranges in delaying spontaneous reactions destructive ways.

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Anxiety Reduction

Goal:

· Reduce anxiety and improve coping skills

Objectives:

· Eliza will become free of panic occurrences (90%)

· Eliza will learn four new ways of coping with routine stressors

· Eliza will develop strategies for thought distraction when consuming the future

· Eliza will report feeling more positive about self and abilities during treatment gatherings

□ Psychotropic Medication Referral & Consultation

□ Journaling

□ Cognitive Behavior Therapy

□ Skill Training

□ Relaxation Techniques - Relaxation techniques are a wonderful way to help a client with stress management.

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Reduce Obsessive Compulsive Behaviors

Goal:

· Reduction in the amount of time spent focused on obsessive thoughts and performing compulsive behaviors

Objectives:

· Eliza will identify the relationship between obsessions and compulsions

· Eliza will perform at least two current activity previously prevented by her OCD

· Eliza will identify at least three behaviors with response prevention

· Eliza will participate in daily relaxation group

□ Psychotropic Medication Referral & Consultation

□ Journaling

□ Cognitive Behavior Therapy - Treats difficulties and increases happiness by changing dysfunctional emotions, behaviors, and thoughts.

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Decrease Sensitivity to Trauma Experiences

Goal:

· Resolve issues related to being arrested for drinking

Objectives:

· Explore and resolve residual stress from underage drinking

· Share details of the trauma with therapist, as able to do so

· Explore spirituality and the role it plays in life after traumatic events

· Reframe negative perceptions, when possible, and focus on finding meaning

□ Verbalize Memories Triggers & Emotion - Can aid a client in maintaining internal balance her daily life by teaching her how to identify and address triggers in the environment that activate problematic issues remembering.

□ Desensitize Trauma Triggers and Memories

□ Utilize Healing Model/Support (Mending the Soul)

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Establish and Maintain Eating Disorder Recovery

Goals:

· Resolve eating disorder

Objectives:

· Be free of binge eating/purging

· Eat a balanced diet of foods and maintain good overall health

· Remove junk foods from home and limit future purchases

· Develop alternative ways of strategies for meeting emotional needs

□ Overcome Denial

□ Identify Negative Consequences

□ Menu Planning – The aim is to increase the average number of healthy food selections on a client’s food menu that comply with dietary guidelines regarding the better food provisions.

□ Nutrition Counseling

□ Body Image Work

□ Healthy Exercise - Regular exercise positively affects integral functions such as brain health and cognition.

□ Trigger Mgmt. Recovery Plan

□ CBT

□ Weekly

□ Biweekly

□ Monthly

□ other: Exercise four to seven times weekly

□ Group

□ Individual

□ Family

□ Maintain Abstinence from substances (Alcohol/Drugs)

Goal:

· Be free of drug/alcohol use/abuse

Objectives:

· Learn five triggers for alcohol and drug use

· Avoid people, places and situations where temptation might be overwhelming

· Explore dynamics relating to the family of an alcoholic in a support group

· Reach twenty-four days months of clean and sober living

□ Substance Use Assessment

□ Step work

□ Overcome Denial - Learning to overcome denial harmful influences that causes a response to ignore problems for which there are solutions for the denying dispositions as well as addresses the need to deal with denial to enhance life experiences.

□ Identify Negative Consequences

□ Commitment to Recovery Program - Recognize personal values and beliefs to pursue change within the client’s belief system. Realize that improvement is valuable, even if it is slow and unsteady in their career and relationships.

□ Attend Meeting

□ Obtain Sponsor

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Increase Coping Skills

Goal:

· Improve coping skills

Objectives:

· Speak concisely so others fully understand

· Spend two hours talking with peers each week

· Accept responsibility for changing own behaviors

· Learn to express feelings verbally without responding negatively

□ DBT Skills Training

□ Problem Solving Techniques - Treatment that helps clients take action in their lives through helping them cope with difficulties and teaching them to proactively solve their problems.

□ Emotion Recognition & Regulation

□ Communication Skills

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Stabilize, Adjustment to New Life Circumstances

Goals:

· Cope with routine life stressors

Objectives:

· Learn four ways to manage frustration in a positive manner

· Talk out routine stress events during weekly therapy sessions

· Implement two new activities that will help mitigate stress

· Learn to use meditation and relaxation techniques daily

□ Alleviate Distress - Learn ways by performing exercises to help improve a range of symptoms and experiences of internal life that are commonly held to be troubling, confusing or out of the ordinary

□ Cognitive Behavior Therapy

□ Stress Management - Prevent stress from occurring by removing the sources of stress and improving the causes of well-being.

□ Skills Training

□ Improve Daily Functioning

□ Develop Healthy Support

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Decrease/Eliminate Self Harmful Behaviors

Goals:

· Free of thoughts of self-harm

Objectives:

· Learn two ways to manage frustration in a positive manner

· Explore triggers of thoughts to harm self or others

· Report feeling more positive about self and abilities

· Explore and resolve stress from the love within

□ Cognitive Behavior Therapy

□ Skills Training - Helping a client in socially relevant behaviors, like communication skills and assertiveness.

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Improve Relationships

Goals:

· Maintain civil and supportive behavior

Objectives:

· Maintain civil and supportive behavior

· Express feelings verbally without acting out

· Connect with healthy people and continue to make new friends

· Explore relationship issues and slowly see new opportunities

· Associate with people outside of work and make one or two new friends

□ Communication Skills - Strategies to determine whether a client’s communication style adequately conveys his or her goals, thoughts, and needs.

□ Active Listening

□ Family Therapy

□ Assertiveness

□ Setting Healthy Boundaries

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Improve Self Worth

Goals:

· Explore and resolve issues related to self-image

Objectives:

· Report feeling more positive about self and abilities

· Discuss life events that reinforce a negative self-image during weekly therapy

· Explore spirituality and the role it plays in the meaning and purpose of life

· Engage in volunteer work activity at least three hours each week

□ Affirmation Work

□ Positive Self Talk - Positive statements encourage clients to cope with distressing times. Clients can say encouraging words and be her own personal coach.

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Grief Reduction and Healing from Loss

Goals:

· Explore and resolve grief and loss issues

Objectives:

· Discuss issues of grief weekly with therapist

· Explore and resolve issues of grief/loss as they arise

· Learn about the typical two to seven-year process of grieving the loss of a loved one

· Explore spirituality and the role it plays in redefining views about the purpose of life

□ Psychoeducation on Grief Process/ Stages

□ Process Feeling - A client learns to understand, make sense of and deal with feelings in healthy fruitful ways.

□ Emotion Regulation Techniques

□ Reading/Writing Assignments

□ Develop/Utilize Support

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family

□ Develop Anger Management Skills

Goals:

· Practice and Increase ability to manage anger

Objectives:

· Be free of tantrums/explosive episodes

· Take a time-out when things get upsetting

· Learn four positive anger management skills

· Learn seven ways to communicate verbally when angry

□ Decrease Anger Outbursts

□ Emotion Regulation Techniques

□ Cognitive Behavior Therapy

□ Increase Awareness/Self Control - Improve a client’s ability to self-regulate or to gain (or regain) a sense of control over her or his behavior and lives.

□ Weekly

□ Biweekly

□ Monthly

□ other: ____________________

□ Group

□ Individual

□ Family