Counseling treatment plan
A woman who is 28 years old comes in for individual therapy. She is single and has never been married. In fact, she has never been on a date. Her personal hygiene is observed to be lacking; her hair is stringy and does not appear to have been washed in several days. She is wearing no make-up, and her clothes are wrinkled. She reports that she is 5’5” tall and weighs over 275 pounds. She shares that she has been overweight since she was a toddler.
She lives by herself in a one-bedroom apartment. Her parents were killed in a car crash when she was twenty years old and she has no brother or sisters. No immediate family members live near her. She does not smoke. She is a social drinker but uses no drugs. She has seen three psychiatrists in her past for depression. She has taken a medication for five-six weeks but has always stopped because she says the medication is ineffective. This is the first time she has made an appointment actual therapy.
She has tried dieting to lose weight numerous times. However, after a month or so, she gives up and gains the weight back plus a few more pounds. She states that she wants to be happy. She wants to have a family someday. She says that she wants to lose weight for her personal health, but she does not know why she can’t stick to a diet program.
She reports no suicidal thoughts. She works as a computer programmer from home. She reports that she spends about 95% of her time alone and at her apartment. She reports no close friends. She reports she is doing well financially because she is a saver and because she wants to retire when she is 55 years of age. She reports that she has received several acknowledgements from her employer for outstanding work and taking initiative. She reports having no hobbies. She works, watches movies, eats and sleeps.
When asked, “Tell me what brought you to therapy today.” She responds, “I want to know what is wrong with me? I want to be healthy and I want to be thinner. I want to do other things, but at my size I lose energy quickly when I am out. Also, I am embarrassed to say that I sweat a great deal, so I don’t like to get around people. I have come to the conclusion that there has to be something wrong with me.”
Treatment Plan for Sample Case Scenario
I. Presenting Symptoms/Issues (i.e., Anxiety, Depression, etc.)
A. Basic Depression
II. Information that Supports Item I. (How did you arrive at the above conclusions?)
A. She stated that she was depressed.
B. She exhibits criteria from the DSM-V (i.e. poor hygiene, low self worth, no close friends, obesity)
C. No close family ties
III. Treatment Theoretical Approach(es): Identify and discuss the major theory(ies) that you, as
the counselor, would use to work with the individual/family and give a rationale for choosing
it/them (Adlerian, Gestalt, Existential, Family, etc.). The approach can be eclectic, a combination
of theoretical approaches.
I would use Ellis’s Cognitive-Behavioral therapy. REBT, specifically, from the Cognitive-Behavioral therapeutic model, allows a client to challenge his/her own negative thoughts which are creating poor outcomes. It provides the client with a solid platform to be able to problem solve outside the session without the therapist.
IV. Treatment Modalities (i.e., Specify Group, Family, Couple, Individual—make sure that
your choice of treatment modalities correlates with what you going to do with the
individuals in the scenario.)
A. I would utilize individual therapy.
V. Reasons for the Chosen Modalities in Item IV
A. She has no immediate family to participate.
B. She is not married or in a serious relationship.
C. She poses no immediate harm to herself or others.
VI. Frequency of Sessions for Each Modality in Item IV
A. Initially, I would see her twice a week for at least one month.
B. Based on her progress, I would move to once a week.
C. I would evaluate eight weeks later to determine future sessions and goals for re-evaluation.
VII. Measurable Treatment Goals (Be sure to state these using action verbs. For example, “The
client(s) will be able to identify, discuss, describe, etc.”)
**These will be agreed upon by both therapist and client.
A. Client will learn the basic chemistry of depression (i.e. AMA readings, Brain Studies)
B. Client will learn how to implement the ABC approach of REBT.
C. Client will how to set short, mid and long-term goals.
D. Client will be able to set her own personal goals outside the session and know how to evaluate success.
E. Client will see a psychiatrist and follow the prescribing recommendations by the psychiatrist.
VIII. Techniques from Theoretical Approaches: Identify and discuss the techniques from the theoretical approach(es) to be used with the situation in the scenario. These should be directly related to Item III.
A. Therapist will implement reflective practices as much as is appropriate.
B. Therapist will utilize the ABC technique to help establish goals
C. Therapist will assist client in summarizing and clarifying her results appropriately.
IX. Frequency for Evaluating Each Goal
A. Since we are using a brief therapy approach model, each goal will be evaluated at the end of each session.
X. How will Progress be Defined? [What will you be looking for regarding progress with your
A. Using the Beck Depression Scale, the client will be evaluated each month.
B. Using self-reporting, client will be asked at the beginning of each session to rate her depression on a scale from 1-10.
C. Therapist will be consulting with prescribing psychiatrist about the effectiveness of medication management.
**All three of the above will be expected to showing gradual improvement over the time indicated in this treatment plan.