Counseling Treatment Plan Paper

Sample Treatment Plan for Counseling Case Study Project

Scenario for Sample Treatment Plan:

Intake Information Collected at first Session:

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. Counseling Treatment Plan Paper

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. Counseling Treatment Plan Paper

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

B.

C.

 

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.

B.

C.

 

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. Counseling Treatment Plan Paper

 

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.

B.

C.

D.

X. How will Progress be Defined? [What will you be looking for regarding progress with your

client(s)?]

 

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.

Counseling Treatment Plan Project

General Instructions

Most of you will have never worked in a therapy session with a client or clients. There is no way to prepare you for that experience unless you begin to think as if you were in that situation. Theories are important to know, but how you will implement the constructs of the theories is so much more crucial. Using the two scenarios below, complete a treatment plan for each one. When you are finished, you should have two completed treatment plans. There are no exact answers because each treatment plan could be approached from dozens of directions. Your outline should be consistent from top to bottom as you think about each scenario. For example, if you state in the beginning of the treatment plan that the client(s)’ presenting issue is depression, then, at the bottom of the outline you should not state that you will be seeing that person once a month. For 99% of the population being treated for depression, once a month would be of very little help. Counseling Treatment Plan Paper

Keep in mind that, even though there might be three or four blanks for you to provide information, you might need less or more blanks to fill in the information that you think is necessary.

You have been provided with a sample Treatment Plan, but you may not use information from that plan in either of the scenarios below.

Note: If specific information is not provided in the scenarios below, you can devise the information if it stays consistent with the other facts. For example, in Scenario #1, you can presume that the client has a Catholic background or a Protestant background; you can presume ethnicity if you deem it relevant.

Scenario for Treatment Plan #1

 

A family comes to your practice for help. Here is the following information that is collected during their intake.

Mom and Dad have been married for twenty years. They have a middle-class income. Mom works twenty hours per week as a para-legal. Dad is a college professor at the local four-year institution. They have three children. The oldest is a 16-year-old girl. She is a straight A student, and she is well liked at her school and the family’s church. She does not play any sports. Her hobbies are reading, art, and theatre club at the school. She just received her driver’s license about three months ago. It is rare that she is ever in trouble and in need of discipline for breaking family or school rules.

The second child is 12-year-old male. This young man seems to find trouble any where he goes during the day. He struggles in school, but the teachers state he is fully capable of completing the work; he just refuses to do the work. He is defiant at school and at home. He spends most of his time defying authority figures who are left in charge of him each day. He can go for days without getting in trouble and then he could go a week getting in trouble every day. Even when he is presented with a “video” of his infraction, he will sit and deny it. He never claims that anything is his fault. He has been known to get into fights at school and even with his older sister. The older sister never fights back. She tries to get away from him rather than engage. He will intentionally break a rule at home and blame it on his older sister or younger brother. Spanking him only makes him madder and more out of control. Time-out ruins everyone’s night because he sits in time-out and verbally says things to bother the rest of the household. The only person he has never shown the behavior is his grandmother on his mother’s side.

The third child is a 10- year-old boy. The boy is identical to the older sibling. He makes good grades and he is well liked by others. He does show some of the “baby of the family” traits. For example, when his older brother picks on him, he immediately cries and screams for his mother. Counseling Treatment Plan Paper

 

I. Presenting Symptoms/Issues (i.e., Anxiety, Depression, etc.) (Spaces are provided for three symptoms or issues, but you may have less or add more, if needed.)

A.

B.

C.

II. Information that Supports Item I. (How did you arrive at the above conclusions? Again, you may have less or more information here.)

A.

B.

C.

D.

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.

 

 

 

 

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.

B.

C.

V. Reasons for the Chosen Modalities in Item IV

A.

B.

C.

VI. Frequency of Sessions for Each Modality in Item IV

A.

B.

C.

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.”)

A.

B.

C.

D.

VIII. Techniques from Theoretical Approaches: Identify and discuss the techniques from the theoretical approach(es) (e.g., reframing, empty chair, etc.) to be used with the situation in the scenario. These should be directly related to Item III.

 

 

 

IX. Frequency for Evaluating Each Goal

A.

B.

C.

D.

X. How will Progress be Defined? [What will you be looking for regarding progress with

your client(s)?]

A.

B.

C.

D.

 

 

Scenario for Case Study #2

A couple enter for their intake regarding pre-marital counseling. They have been dating for approximately fifteen months. They are wanting to get married; however, they are concerned with several issues. The woman has been married twice before. She has one child with each of her past ex-husbands. She has an eight-year-old girl and a four-year-old boy. The man has been married once before. He has one child, a boy, age 13.

Both woman’s ex-husbands play a large role in the children’s lives. However, the man’s ex-wife has nothing to do with her son. The woman receives a large alimony check that she would lose if she re-marries. This is a concern since she does not work outside the home. The man has a good job, but they would be living on a tight budget without her alimony check each month. They have discussed living together, but, if it is proven that they are cohabitating, she would still lose the alimony. The children have not met each other at this point. The woman’s ex-husbands are not aware that she has been in a serious relationship. Counseling Treatment Plan Paper

The 13-year-old boy has been in trouble with the juvenile court system for inappropriately touching girls at school. The last episode was six months ago. He has been in counseling for over one year. The man has not told the woman of his son’s issues.

Again, they have come in for pre-marital counseling and how they should tell the children the news if they decide to marry.

I. Presenting Symptoms/Issues (i.e., Anxiety, Depression, etc.) (Spaces are provided for three symptoms or issues, but you may have less or add more, if needed.)

A.

B.

C.

II. Information that Supports Item I. (How did you arrive at the above conclusions? Again, you may have less or more information here.)

A.

B.

C.

D.

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.

 

 

 

 

 

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.

B.

C.

V. Reasons for the Chosen Modalities in Item IV

A.

B.

C.

VI. Frequency of Sessions for Each Modality in Item IV

A.

B.

C.

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.”)

A.

B.

C.

D.

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.

 

 

 

 

 

IX. Frequency for Evaluating Each Goal (Will you evaluate after each session? …after

two sessions? etc.)

A.

B.

C.

D.

X. How will Progress be Defined? [What will you be looking for regarding progress with

your client(s)?]

A.

B.

C.

D.

 

Scoring Guidelines

 

Points available: 100.

Component	Unacceptable	Acceptable	Target
Treatment Plan #1 Categories	Responses to 1 or more categories are missing; information is inaccurate, and key ideas are not well (0 points)	Responses to all 10 categories is provided, information is accurate, but explanations of key ideas are vague and not well supported (10 points)	Responses to all 10 categories are comprehensive, accurate and complete; key ideas are clearly stated, explained, and well supported (20 points)
Treatment Plan #1 Knowledge of theories, models, and strategies for understanding and practicing consultation is evident. (CACREP 2F.5.b)	Knowledge of theories, models, and strategies for understanding and practicing consultation is limited or inaccurate; choices are inappropriate and/or not supported (0 points)	Knowledge of theories, models, and strategies for understanding and practicing consultation is demonstrated; choices are appropriate, but not well supported (5 points)	Knowledge of theories, models, and strategies for understanding and practicing consultation is evident; choices are appropriate and well supported (10 points)
Treatment Plan #1 Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is evident. (CACREP 2F.5.i)	Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is limited or inaccurate; choices are inappropriate and/or not supported (0 points)	Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is demonstrated; choices are appropriate, but not well supported (5 points)	Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is evident; choices are appropriate and well supported (10 points)

 

Component	Unacceptable	Acceptable	Target
Treatment Plan #2 Categories	Responses to 1 or more categories are missing; information is inaccurate, and key ideas are not well (0 points)	Responses to all 10 categories is provided, information is accurate, but explanations of key ideas are vague and not well supported (10 points)	Responses to all 10 categories are comprehensive, accurate and complete; key ideas are clearly stated, explained, and well supported (20 points)
Treatment Plan # 2 Knowledge of theories, models, and strategies for understanding and practicing consultation is evident. (CACREP 2F.5.b)	Knowledge of theories, models, and strategies for understanding and practicing consultation is limited or inaccurate; choices are inappropriate and/or not supported (0 points)	Knowledge of theories, models, and strategies for understanding and practicing consultation is demonstrated; choices are appropriate, but not well supported (5 points)	Knowledge of theories, models, and strategies for understanding and practicing consultation is evident; choices are appropriate and well supported (10 points)
Treatment Plan #2 Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is evident. (CACREP 2F.5.i)	Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is limited or inaccurate; choices are inappropriate and/or not supported (0 points)	Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is demonstrated; choices are appropriate, but not well supported (5 points)	Knowledge of evidence-based counseling strategies and techniques for prevention and intervention is evident; choices are appropriate and well supported (10 points)
Overall Organization and Clarity	No organizational structure; absence of support for main points (0 points)	Organization is confusing or disjointed; support is provided, but is not specific; support is only loosely relevant to the main points (5 points)	Clear organizational structure; ideas sufficiently supported; support is sound, valid, and logical (10 points)
Professional presentation (grammar, mechanics, spelling)	Writing involves many errors (more than 3) (0 points)	There is some deviation from college level writing; writing involves few errors (no more than 3) (5 points)	Graduate-level writing is used; writing is free of all writing errors (10 points)