Treatment Plan Report

Doneil R. Jones
Clinical Psychology
Email: [email protected]

Author Note
The author is a doctoral student at Capella University of Minneapolis.
E-mail: [email protected]
Manuscript original first printing on 10 December 2014

Lilith Redgrave's Treatment Plan

Problem: Anxiety
Definition: A generalized state of apprehension or foreboding (Nevid, Rathus, Greene, 1994).
Anxiety affects thinking, perception, and learning. It tends to produce confusion and distortion of
Perception, not only of time and space but also of persons and the meanings of events (Sadock,
2007). The anxiety can be triggered both internally by aggression, sexuality, emotions, thoughts
or chemicals. Anxiety can also be triggered via external triggers which can come from the clients
environment.
Continuing fear and over-exaggerated concern over specific and menial tasks, situations or
environments which bear no rationality.
Physical features include: jumpiness, jittering, heavy perspiration, light-headedness,
feeling irritable, nausea, nervousness (Nevid, Rathus, Greene),
palpitations, tensing muscles.

Goals:
1. Assess client's behavior and investigate the source of anxiety.
2. Gain a clear understanding of when and where the anxiety started.
3. Build trusting relationship with client that fosters stability and consistency.

Objectives:
1. Assess the clients immediate concerns.
2. Identify anxiety triggers
3. Discover what may have and/or is existing in her immediate environment that has played
and/or plays a part in triggering the anxiety.

4. Identify how the client has been coping with anxious feelings on her own
5. Evaluate for necessity for continuation of medication and whether client is taking appropriate
medications and dosages.
6. Help client to acknowledge the personal strengths that she may be overlooking.

Long-Term Goals:
1. Help client to increase her ability to cope in the face of anxiety provoking situations.
2. Help her to find closure with any unresolved issues that may be at the root of the anxiety
3. Help client to develop positive and more accepting feelings about herself in the face of
anxiety provoking situations

Interventions:
1. Establish a productive level of rapport and trust with the client
2. Ask probing questions to determine the nature of the presenting issue and its underlying roots.
3. Trust in clients inner strengths and trust in her ability to overcome her most memorable traumas
and anxiety stressors
4. Provide an embracing environment and the therapeutic conditions that can allow client to
grow beyond social apprehension.
5. Help client work client through the stages of change to successful termination
6. Assist client in clarifying the complications in any feelings that may be responsible for
Experienced disorientation.
7. Assist client in identifying the value and Importance of disclosing feelings during therapy.
7. Display unconditional positive regard for client by showing confidence in her and fostering
a relationship which supports her competence.
8. Therapy will consist of active listening, open displays of empathy and understanding without
placing any criticism or judgments against her or her decision making faculty.

9. Help client to learn acceptance over the possibilities that she may not have control over.

Diagnosis: 308.33 Acute Stress Disorder Severe without Psychotic Features

Problem 2: Depression
Definition:
Symptoms: Client experiencing listlessness, lack of interest in former enjoyable activities,
suicidal ideation, exhaustion, excessive introversion, diminished self-esteem, history of
reoccurring symptoms and currently taking antidepressants.

Goals:
1. Help Client to reduce depressive symptoms.
2. Help Client to reduce the impact that depression inducing environments and situations
normally have upon the client.
3. Help client to learn to feel more comfortable with her ideal self.

Objectives:
1. Have client describe and define her depression.
2. Identify clients depression triggers and suicidal ideations.
3. Discover what may have and/or is existing in her immediate environment that has played
and/or plays a part in triggering the depression.
4. Find what the client has been doing to alleviate her depressive emotions and thoughts.
5. Evaluate if client is actively taking her medications and whether the appropriate dosages
are being taken as well.
6. Help client to unearth unresolved and repressed issues that may contributing to depressive
states.

Long-Term Goals:
1. Help client to increase her ability to cope in the face of depression provoking situations.
2. Help her to find closure with any unresolved issues that may be at the root of her depression.
3. Show client consistency through the therapeutic relationship, plus help her to trust to learn
ideas, alleviate feelings of depression.

Interventions:
1. Establish a good level of rapport and trust with the client
2. Ask probing questions to determine the roots of depression.
3. Probe to gather an inventory of all most impacting traumas and stressors
4. Help client recognize and heal through old issues and learn how to let go of limiting beliefs
about them.
5. Help client work client through the stages of change to successful termination
6. Possiblilty for referral to womens support group. Block and Robbins found that the high
esteem women valued close relationships with others (Pervin, Cervone, Oliver, 2005).

7. Assess client's suicidal temperament with a suicidal ideation questionaire.

8. Help client to learn acceptance over the possibilities that she may not have control over.

Diagnosis: 308.33 Major Depressive Disorder, Recurrent; Severe without Psychotic Features

After initially seeing Lilith, it became apparent that she suffers from two different
types of disorders. Lilith was assessed for diagnosis and it was important to determine to

what degree that she had been affected. The diagnosis of a mood disorder depends on the
intensity and duration of the mood disturbance, its accompanying symptoms, and the degree
to which it interferes with the individuals social and occupational functioning (Fauman,
1994) and basic panic attacks can occur in the context of any Anxiety Disorder as well as
other mental disorder; e.g., Mood Disorders, Substance-Related Disorders (APA, 2000). She
struggles with both severe anxiety and depression. After reviewing the DSM-IV, her
symptoms have been narrowed down to resemblances of 308.33 Major Depressive Disorder,
Recurrent; Severe without Psychotic Features and 308.33 Acute Stress Disorder Severe
without Psychotic Features.

Above are listed two treatment plans which include accounts of observed
symptoms of the client and the projected goals which are intended to be utilized as plans of
action to the client, in order that she may learn to develop into a more socially and personally
functional individual. Therapy is also intended to help the client to realize her human
potential through a supportive and caring therapeutic relationship. Person Centered Therapy
rests on the assumption that the practicing therapist can help clients overcome the negative
effects that her past experiences have had on her attitude feelings and behavior (Cepeda &
Davenport, 2006). These treatment plans which have been submitted are based upon a
general overview of the clients presenting issues and a description of the symptoms of
which she has reported thus far. The treatment plans are subject to change as she continues to
be seen and more is learned about her situation throughout the course of treatment.

History
Lilith reports that since she has moved to the new neighborhood she is becoming
more uncomfortable within social situations. Lilith explains that when she feels like she is
under pressure from clients at work, her boss or her boyfriend at home then she panics and
cannot function. She has always worked in customer service, but it is becoming more
difficult for her to operate in her current line of work. She says that too many people around
her make her nervous and she feels like sometimes theyre staring and talking about her. She
reports feeling nervous when she is at work and she would much rather just be alone most of
the time now-a-days.
In addition, Lilith explains that she has been having a harder time getting out of
bed in the morning as usual. She says that she just cant deal with things anymore and
some nights she cries outside in the parking lot at her job before she goes home at night.
Depression is normally associated with an unpleasant emotional state; a changed attitude
towards life and somatic symptoms of a specifically depressive nature (Beck, 1967). She has
admitted that she has trouble getting to sleep, but when she does then she doesnt ever want
to wake back up ever again. These words are of concern because according to the DSM-IV,
individuals experiencing Major Depressive Disorder is associated with high mortality. Up to
15% of individuals with severe Major Depressive Disorder die by suicide (DSM-IV-TR).
Lilith will need to be assessed to decipher just how much does she ruminate upon thoughts of
suicide and how much of a risk is she to herself.
Lilith also explained that her family is very against her relationship with her
boyfriend of three years which also stresses her out. She says that moving in with him has

created a rift between her and her family and her symptoms had not started until after 6
months after moving in with him.
Observation: Mental Status Evaluation: Anxiety
Lilith did not immediately appear to be struggling to cope with anxiety, but her
anxiety level did peak while she explained the experiences that she has been having while
facing anxiety provoking situations. Her physical symptoms of anxiety began to reveal
themselves as she explained further.
As Lilith disclosed further, she seemed to be very withdrawn and on edge. When she
talked her eyes were normally cast down and she made eye contact very briefly before she
cast her eyes either to the left or right or toward the floor. Her body language was reserved
and she became very defensive when asked about her boyfriend. There was a bruise on her
right forearm that she refused to discuss.
She explains having lightheadedness and dizziness. She says that she feels it during
the times when she is most anxious. Lilith goes on to explain that her heart beats very fast
and these episodes can occur when she is very stressed, when she has had little sleep or
sometimes for no reason at all. Sometimes she is afraid that she will have a heart attack.
Even as Lilith is explaining this, it appears that she getting extremely excited and out of
breath. She took her sweater off because she said that it was starting to get hot in the room.
She expressed herself with a great deal of desperation and she was scratching her palms.
When asked about her itching palms, she explained that she can feel tingling sensations in
her scalp as if they were about to go numb, sometimes it is accompanied by head pressure

and congestion. She says that it always goes away after she calms down or when her panic
attacks are over. She describes the feeling as an intense desire to run away or to escape.
Observation: Mental Status Evaluation: depression
Additionally, Lilith also exhibits symptoms of depression as well. She did
complain of issues with hopelessness, despair, social withdrawal and prolonged sadness, but
what was also interesting were her complaints of physical aches and pains as well. She
complained of frequent headaches which sometimes can either last and hour, a few hours and
sometimes a complete day. She mentioned that her back aches sometimes and does not recall
ever injuring herself.
Some of Liliths other physical symptoms were red eyes which appeared as if she
was crying recently. There was also listlessness in her voice as she talked as well. Her hair
was pushed back in a pony tail. Her clothes were slightly wrinkled. She shared how she
would usually wear make-up and do her hair, but now she does not really care. She had a
despairing look in her eyes as she explains how she feels like dying inside because nothing
feels meaningful anymore, including the therapy. She hopes that therapy can help her feel
like herself again instead of feeling so empty.
Therapeutic Orientation
Person Centered Therapy is a very nurturing and supporting type of therapy that
rests upon three core principles which are unconditional positive regard, empathy and
genuiness (congruence). Clients are fully accepted. The idea is that the entire person is
welcome flaws and all and all are one. Empathy is having the ability to enter into and
understand the world of the client and to have the ability to convey this understanding (Egan)

in a language they are in sync with. Congruence is when a state of equilibrium has been
established between client and therapist and there are no walls existing between them. The
client perceives that the therapist is a real person who has feelings, thoughts, and beliefs that
are not hidden behind facades (Capuzzi & Gross, 2007).
The client is allowed to be themselves and express themselves within their own
element because the goal is to allow the client to discover themselves through the
achievement of a trusting and non-judgmental client-therapist relationship. This therapy will
seek to help Lilith acquire control over her inner resources. She will learn that she has more
potential than she uses most of the time and that success is found in the journey rather than
the preconceived goal (Capuzzi & Gross, 2007). It is through the above mention three
principles of therapy that this goal can even be approached.
Person centered therapy demonstrates faith in the whole person rather than
denigrating clients for mistakes of behavior which allows clients the freedom to explore their
inner world without fear of rejection (Capuzzi & Gross, 2007). The goal is also to get the
client functioning fully because when people are functioning fully, they are free to
experience and satisfy their inner natures, they show themselves to be positive and rational
creatures that can be trusted to live in harmony with themselves and others (Hjelle, Ziegler,
1992). The client can then learn to feel autonomous of her own free volition. Person centered
theory believes that lifes master motive is the actualization tendency which entails that the
intention of an individual is to maintain and enhance the self, in order to become the best self
that their inherited natures will allow them to be (Hjelle, Ziegler). The client wants to be
good and wants to be better and person centered therapy helps a person to become more
whole and integrated and individualized.

Treatment Plan
Lilith will need to be treated for both anxiety and depression because the two can
have a tendency to work together against an individual in many cases. There is also a high
tendency of medical symptoms such as headaches (reported by 49% of depressed patients)
palpitations reported by 94% of anxiety neuroticism (Beck, 1967) afflicted patients.
The treatment for her depression will formulated around three supportive methods.
Lilith will be offered guidance, ventilation and reassurance. As a therapist who practices
from a person centered perspective, Lilith will be offered an environment where she can feel
safe and comfortable. A person can at times associate and equate emotional problems with
weakness and character defects (Beck) therefore patients will tend to restrain from discussing
issues with those closest to them, in order to save face and retain ones own dignity.
Therefore, therapy will allow the client the ability to ventilate her issues without feeling the
pressure or embarrassment that is normally associated with social judgment.
Additionally, depression and anxiety are self-limiting disorders which perpetuates
beliefs that the client will never get better (Beck) and that the clients world is a threatening
place. It is important that the client is fully supported and accepted, in order to help restore
hope. It needs to be made clear for the client that getting better is realistic and possible, but
only through work and time. Several studies have shown that client gain is significantly
correlated with the attitudes of congruence, accurate empathy, and positive regard (Corsini,
1984). So, the client will be provided with therapy that is caring, genuine and honest.
Furthermore, clients who perceived more of the three attitudes in their therapist showed more
positive gain in therapy than those who did not perceive these attitudes (Corsini). In addition,

in order to restore the clients sense of hopefulness, it is best to be supportive and to provide
the necessary guidance, but also the client needs to believe in herself. The therapy needs to
maintain a focus in which the goal is to help the client to become self sufficient and fully
functional in her personal and professional environment. Therefore, as a therapist, it is
important to believe in the self-directing ability of the client and to help the client to realize
the self directing ability that she has over her life.
Lilith is not known well enough to have an expansive understanding of her
temperaments, but it is clearly understood that she is reluctant to fully disclose all aspects of
her problems. She is very withholding on topics revolving around her boyfriend, but she is
more expressive about other topics about her life, in particular, she is more comfortable
expressing feeling and experiences about and within herself. Based on the fragility of the
beginning stages of the therapy; the client will not be challenged until the therapeutic
relationship is more developed and trust is established.
In conjunction with establishing trust in the therapeutic relation, being that the
relationship is fragile; the client may find certain expressions of empathy too intrusive; yet if
she is resistant at times and finds the empathy too directive then it will be necessary to know
when and when not to respond empathetically (Norcross, 2002). During therapy, the process
will be diagnosed from moment-to-moment to decipher when to follow up with what types
of empathy to offer and to which degree should it be interjected. Through active listening and
appropriate empathy, the implicit information that may not be in the foreground of her
narratives (Norcross) can be extracted and explored. Even more, Person centered therapy
recognizes that clients bring to the therapeutic relationship values, abilities, knowledge and

experiences as well as disabilities, limitations and unique living contexts that influence their
lives (Jamieson, Krupa, ORiordan, Oconner, Paterson, Ball and Wilcox, 2005). So, by
being receptive to the clients needs; there may be new opportunities opened up in terms of
helping the client heal.
Overall, Lilith appears to be seeking to reclaim her ideal self. The ideal self is the
self-concept that an individual would most like to possess (Pervin, Cervone, Oliver, 2005).
This therapist acknowledges that she is currently seeing two separate versions of herself. One
version is the self that she would like to emulate and the other is the self of who does not
want to be anymore. The latter is the self that drains her, scares her and threatens her health
and well being. The ideal self will empower her, but it will be through successfully
committing and cooperating with therapy that her faith in herself may be gained and restored.

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