MCC 670 – Treatment Plan

​The Purpose of a Treatment Plan…

The purpose of a treatment plan is to address the “HOW of therapy” (Ingram 2012 p. 95).  It acts as a guide for the counselor throughout the therapy process.  When developing your treatment plan, it is useful to look at the information gathered from your IDI and ask how this strategy can help the client achieve their goals?  Or in other words, what problems is it designed to address?

BOOK EXAMPLE:  “In order to help the couple effectively manage conflict…(Outcome Goal), I will use Hendrix’s imago therapy (Strategy)…Family therapy is the treatment of choice (Strategy) to reduce Johnny’s Oppositional Behavior (Outcome Goal).

Standards for Creating a Treatment Plan…

  1. STANDARD #21: The plan is focused on resolving the identified problem and achieving outcome goals” (Ingrams, 2012, p. 95).
    1. Does strategy stray from plan?
    2. Write strategy and problem in one sentence (see above).
  2. STANDARD #22:  The plan follows logically from the hypothesis and does not introduce new data.
    1. Does your plan have no “foundation in the hypothesis section? (Ingram, 2012, p. 98).
    2. Do you have a hypothesis with no plan to address it? (Ingram, 2012).
    3.  If you see new data in plan, need to add to database, or eliminate it from the plan.
  3. STANDARD #23;  The plan is informed by knowledge of research literature.” (Ingram, 2012, p. 99).
    1. Check remaining posts from MCC 670.  They provide examples of how relevant research and theory can guide your treatment plan.
    2. Evidence Based Practices are required by third-party payers…
  4. STANDARD 24:  There is clarity regarding strategy, sub-goals and process goals; procedures and techniques; priorities and sequencing and the desired client-therapist relationship” (Ingram, 2012, p. 100).  What follows are a few relevant considerations…
    1. New therapists might include more information to guide their efforts.
    2. The number of sessions allowed by insurance and affect how much detail is required.
    3. Some clinical hypotheses requre more detailed and specified plans.
    4. “The plan should describe what kind of relationship is desired and what should be avoided” (Ingram, 2012, p. 101).
    5. Specify the sequence of interventions in your plan (Early/Middle/End).
  5. STANDARD #25: “The plan is taylored to the specific client; Such factors as gender, ethnicity, sexual orientation, and spiritual are considered” (Ingram, 2012, p. 103).
    1. Cultural Competency is important in the development of rapport (I.e. language, relationships, metaphors, relationships, boundaries, body language) and to create strategies relevant to the client.  (Ingram, 2012).
    2. Other considerations:  Stages of change; amount of structure; and levels of authority displayed by the therapist (Ingram, 2012).
  6. STANDARD #26:  The plan is appropriate for the treatment setting, contractual agreements, and financial constraints” (Ingram, 2012, p. 107).
    1. What is insurance willing to prove?
    2. WHat sort of therapy modality is utilized at your facility?
    3. What are the clients motivations, expectations, and resources?
  7. STANDARD #27: The plan incorporates community resources and referrals” (Ingram, 2012 p. 108).  Be aware of community resources available….
  8. STANDARD #28:  The plan addresses legal, ethical and mandated reporting issues.” (Ingram, 2012, p. 109).  Be knowledgeable of legal and ethical standards…

A Sample Treatment Plan…

Client Last Name, First Name, MI: Jones, Illana, T.

Address: 1234 Something Street

City, State, Zip: Everywhere, NE 12345

Telephone (s): (402)-123-4567

Parent/Guardian (if client is a dependent): N/A

Informant (if other than the client): N/A

Client SSN: 111-11-1111

Place of Birth: Indianapolis, Indiana

Date of Birth: ​09/21/1986​​​

Age: 28

Gender: ​Female​​​​

Race: Hispanic/Latino

Chief Complaint/Presenting Problem:

Client is a 28-year-old mother married mother of two young children, who currently lives in base housing. She has been referred by the base doctor after complaining of depressive symptoms and failing to contract for safety. She appears significantly underweight, cries easily and complains of a debilitating depression.

Diagnostic Impression:

• 296.32 (F33.1) – Major Depressive Disorder, Severe, Recurrent Episode
• 307.1 (F50.02) – Anorexia Nervosa, Binge-eating/Purging type, Moderate.
• 995.53 (T74.22XA) Child Sexual Abuse, Initial Encounter
• V15.59 (Z91.49) Personal History of Self-Harm
• Rule Out – Suicidal Behavior Disorder

Case Formulation (biopsychosocial history and MSE) Summary:

Biopsychosocial History
  1. Emotional/Psychiatric History – The client’s psychiatric background includes a diagnosis of major depression, anorexia nervosa, and self-harming behaviors. History of self-harm includes cutting behavior and a distant hospitalization in eighth grade for a suicide attempt. Cutting behavior onset in eight grade, includes small cuts and eraser marks on skin to relieve stress. Significant history of anorexia, binge-purge type, starting in eighth grade. Latest psychiatric hospitalization to stabilize anorexia after her daughter’s birth when she gained 40 pounds. Previously prescribed antidepressants, but stopped taking them. Is not currently being followed by a mental health provider. Her current symptoms include feelings of worthlessness, social isolation, fatigue, and suicidality with no plan in place. Patient is also notably tearful and significantly underweight.
  2. Social History – Ilana is a 28-year old stay-at-home mother of two young children ages 3 and 5. She has been married to her husband, David, for seven years. She recently moved into base housing three months ago, after a series of job-related transfers due to her husband’s line of work. Describes the frequency of these transfers as difficult for her, and complains of isolation after their latest move.
  3. Family of Origin: The client was born to Umberto and Guadalupe, restaurant owners in a small Midwest town. She reports her early childhood as mostly “idyllic” and states her large extended family played a significant role in her daily life. Her older sister, Reyana is just two years her senior. Ilana describes an unhealthy competitive relationship with her sister and feeling like the “ugly duckling”. Mother’s concern for her weight at this time further exacerbated these insecurities. Ilana’s eating disorder history has an onset at about this time as well.
  4. Academic & Intellectual History – Ilana’s academic history is unremarkable. She reports she was a always a good student. Holds a bachelor’s degree in psychology.
  5. Employment History – The client is a stay-at-home mother with no recent employment history and no plans to return to work with two young children at home.
  6. Cultural and Religious Background – Ilana describes herself as “not very religious” although states she was raised in a large Catholic family. While Ilana grew up in a small predominantly white community, she was raised by a large Hispanic family with rich cultural traditions. She expresses great appreciation for this culturally diverse background.
  7. Medical History – Ilana’s developmental history is largely unremarkable. Ilana mentions a growth spurt in junior high resulting in a significant weight gain, at which point her mother started her on Weight Watchers. Pregnancies described as difficult due to weight gain and exacerbation of eating disorder symptoms. Hospitalization required after oldest child to stabilize eating disorder symptoms. Youngest child born two months early, resulting in exacerbation of depressive symptoms.
  8. Legal History – N/A
  9. Offender Issues – N/A
  10. Victim Issue – Ilana reports an incidence of sexual abuse involving fondling by a great uncle when she was five. While she remembers little about the incident, she states her family was quite emotional and entered counseling as a family to address this issue.
  11. Substance Abuse History – Ilana does not drink, smoke, or use illicit drugs.
Mental Status Exam
  1. Appearance – The client is a well-groomed 28-year-old female who appears her stated age. Is extremely underweight with cuts marks along inner thighs and arms.
  2. Behavior – Crying and tearful throughout the interview.
  3. Cooperation – Client is cooperative throughout the interview although mentions her reluctance to be here.
  4. Speech & Language – Client’s speech is articulate and coherent. Nonetheless, she is minimally responsive to the therapist’s questions.
  5. Thought Form & Content – Thought processes are goal-directed and coherent. Transient thoughts of self-harm with no plan in place.
  6. Mood & Affect – Mood and affect appear congruent. Client complaints of debilitating depression and is tearful throughout interview.
  7. Perception – Unremarkable.
  8. Level of Consciousness – Client is alert and oriented.
  9. Insight & Judgment – Partial insight noted in light of limited capacity to understand underlying issues. Judgment poor in light of inability to make reasonable decisions pertaining to adequate self-care.
  10. Cognitive Functioning – Unremarkable.
Problems (specific concrete behaviors):
  1. Unmanaged Depression
    1. As evidenced by Psychological Evaluation
    2. As evidenced by depressive mood and affect.
    3. As evidenced by suicidal ideation.
    4. As evidenced by feelings of worthlessness and isolation.
  2. Inability to maintain healthy weight
    1. As evidenced by BMI of 16 during doctor’s exam.
    2. As evidenced by report of binging and purging behaviors.
    3. As evidenced by inadequate food intake.
  3. Difficulty coping as manifested in cutting behavior.
    1. As evidenced by visible cuts on arms and thighs.
    2. As evidenced by client’s report of cutting behavior to “feel better”.

Hypotheses (etiology):

  1. Exacerbation of depression due to poor understanding of underlying symptomatology and discontinuation of medication.
  2. Increase in suicidal ideation and cutting behavior due to deficient coping skills and ongoing rumination with poor metacognitive insight into thought processes.
  3. Re-emergence of eating disorder behavior due to poor self-care, low self-worth, and a feeling out of control with binging and purging habits. Onset associated with competitive relationship with sister, and criticism from mother for weight gain in junior high.

Treatment Goals (mutual):

  1. PROBLEM – Unmanaged Depression
    1. GOAL ONE – Symptoms of depression will be significantly reduced until they no longer impede with daily functioning.
      1. OBJECTIVE ONE: Ilana will take all medication as prescribed and attend all scheduled meetings this month.
      2. OBJECTIVE TWO: Ilana will develop increased understanding of maladaptive thought processes underling depressive feelings as a result of participation in DBT Skills Group.
        1. INTERVENTION: Therapist provides referral to DBT Skills Group and forwards case information to provider, Jane Doe LMHP.
          o Responsible Party – Kathleen Johnson, Future LMHP
        2. INTERVENTION: Jane Doe, LMHP monitor’s Ilana’s progress and provides her therapist with relevant updates
          o Responsible Party – Jane Doe, LMHP
      3. OBJECTIVE THREE Ilana will develop a safety-plan with her husband and report no suicidal thoughts for one month.
    2. GOAL TWO – Overcome resistance to therapy, and develop solid therapeutic relationship as evidenced by commitment to therapy and open communication.
      1. OBJECTIVE ONE: Ilana will discuss with therapist the nature of her resistance to therapy in this month’s sessions.
      2. OBJECTIVE TWO: Ilana will discuss what she hopes to achieve in therapy and commit to active participate
      3. OBJECTIVE THREE: Ilana will discuss her concerns and any areas of disagreement with the therapist should they come up at any point in time.
  2. PROBLEM – Inability to Maintain Healthy Weight
    1. GOAL ONE – Restore healthy body weight.
      1. OBJECTIVE ONE: Ilana will visit her physician weekly for regular weigh-in’s.
        1. INTERVENTION: Physician will monitor Ilana medically and forward information as necessary to her therapist.
          o Responsible Party – Base Doctor.
      2. OBJECTIVE TWO: Ilana will record her daily dietary intake with her husband’s assistance and monitoring.
      3. OBJECTIVE THREE: Adherence to dietary recommendations of primary care physician as indicated by food log.
    2. GOAL TWO – Reduce binging and purging behavior.
      1. OBJECTIVE ONE: Client will closely monitor self care, listen closely to her bodily cues.
      2. OBJECTIVE TWO: Ilana will avoid people and places that tend to trigger any urges to engage in binging and purging behavior.
        1. INTERVENTION: Therapist will assist Ilana this month in developing a list of triggers for her binging and purging behavior.
          o Responsible Party: Kathleen Johnson, Future LMHP.
        2. INTERVENTION: Therapist will assist Ilana in developing strategies to avoid these triggers.
          o Responsible Party: Kathleen Johnson, Future LMHP.
    3. GOAL THREE – The client will build a healthy self-esteem.
      1. OBJECTIVE ONE: Eating disorders will no longer be the focus of her interactions with sister and mother.
      2. OBJECTIVE TWO: Ilana will develop positive self-talk and healthy coping strategies.
  3. PROBLEM – difficulty coping as manifested in cutting behavior
    1. GOAL ONE – Gain insight into the reasons for cutting behavior.
      1. OBJECTIVE ONE: Ilana will develop greater emotional awareness and learn alternative methods for regulating emotions.
        1. INTERVENTION: Ilana will learn emotional regulation skills in a weekly DBT Skills Group.
          o Responsible Party: Jane Doe, LMHP
        2. INTERVENTION: Therapist will discuss with Ilana, her DBT Skills Group homework in individual sessions.
          o Responsible Party: Kathleen Johnson, Future LMHP
      2. OBJECTIVE TWO: Ilana will identify a list of self-harm triggers with her therapist next session.
    2. GOAL TWO – Find alternative methods of coping as a healthy replacement for cutting behavior.
      1. OBJECTIVE ONE: Ilana will utilize DBT skills in order to regulate emotions in a healthy manner.
      2. OBJECTIVE TWO: Ilana will develop a list of soothing techniques, to calm persistent negative feelings with her therapist during the next session.
      3. OBJECTIVE THREE: Ilana will work develop a list of activities that can allow her to release or expressing painful emotions during the next session.

Supports:

The client’s extended family is very supportive. She has a loving husband and is motivated by her desire to be a good mother to her children.

Obstacles

Ilana’s reluctance to seek therapy is concerning. Additionally she displays low self-esteem as evidenced by her assertion that “I’m a terrible wife and mother”. These statements are also indicative of low insight into the affect of depression on her thought processes.

Additional Information Needed

Treatment team includes Ilana’s base doctor who will monitor her weight regularly. In-house Psychiatrist will follow for pharmaceutical treatment of depression. Jane Doe will also be conducting a weekly skills group, which Ilana expected to participate in.

Assessment Measures to Track Progress

Ilana will visit her base doctor weekly for weight monitoring. Psychiatrist will assess client monthly to monitor her response to medications. Therapist will assess client’s depressive symptoms and suicidal ideation monthly in order to determine her baseline.

Treatment (model, location, therapist style, focus, frequency)

Individualized therapy to occur weekly in conjunction with weekly DBT group meetings.

Pharmaceutical Treatment

Client is referred to in-house psychiatrist for evaluation this week. Pharmaceutical Treatments to be determined at this time.

Adjunct Treatment(s), (e.g. support groups)

Client referred to Dialectical Behavioral Therapy Skills Group as an adjunct treatment to individualized therapy. Information on eating disorder support groups has also been provided.

Prognosis

Prognosis guarded due to the client’s reluctance to participating in therapy and inadequate following through with treatment recommendations. The multifactorial nature of Ilana’s issues significantly increases the need for close management and ongoing support.

_____________________________​______________
Signature, Title​​​​​/Date

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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