Case Formulation and Treatment Plan

Case Formulation and Treatment Plan

Ellice was brought in by her mother. The mother said that she had found her in her home on her bed and that it seemed like she had been there for a while because she found her covered in urine and sweat and it looked like she hadn’t showered for days. That is when the mother decided to intervene. Ellice did not look unwilling to be there though she seemed distracted most of the time and when asked a question she would start giving an explanation and halfway through lose her trail of thought and respond with “I’m sorry, I forgot what you had asked”. She was very reluctant to talk. Most times Ellice was staring into objects and her attention was never on my questions.

The mother describes Ellice as being very interactive and active in group activities when she stayed at home but Ellice says that since moving out she does not make a lot of friends and mostly keeps to herself. She would visit home on the weekends but the mother said she had not seen her for a month before she decided to go see her. Her friends back home reached out to the mother that Ellice had not been communicating much with them. Ellice says she feels like they really don’t want to be her friends but are just pretending.

Ellice is in campus through a partial scholarship from her church. However, her grades have been low lately and she says she does not understand why she is failing despite her hard work. The mother says she was very bright in high school that is how she got the church funding. Ellice says she found out about 2 months ago that she might lose the scholarship and she started looking for work to help funding.  She keeps to herself most times but she justifies it with she does not have much time for anything else..

When asked about the situation her mother found her in she says that she just did not feel like doing anything. Further inquiries revealed the following: two weeks earlier she had received her CAT results and she had failed again. She requested for extra credit exams and therefore had not been eating well in the week following. Working to part time jobs meant she was constantly fatigued and was eventually fired from one of them because she “lacked concentration” and was therefore not delivering results. Ellice believes that nothing she does is good enough and she does not feel like trying anymore.

TREATMENT PLAN

Date of Exam:

Time of Exam:

Patient Name: Ellice

Patient Number:

Patient DOB:

A treatment plan was created today, (insert date).

Meeting Start: (insert time)- Meeting End: (insert time)

This was an Initial Treatment Meeting.

Participants Developing the Plan:

(Student name) (Counselor)

Ellice (Client)

(Client’s mother)

DIAGNOSIS:

1. Major depressive disorder, single episode, moderate. F32.2 (ICD-10) (Active)(Koukopoulos & Sani, 2014).

Justification of diagnosis: Ellis gives a description of a sad feeling every day since she got the letter concerning her college funding. She also isolates herself from people-not responding to friends’ calls and texts, stopped visiting the mum, spends most times indoors trying to figure out her grades. Carries feelings of no energy to leave the bed and feelings of nothing she does works

MEDICATION:

Ellice is currently not on any medication since it is her first session. She has been made aware of the costs and benefits of medication. Does not wish to start a medication at this time. It is her first episode, she will be under observation to decide if medication is needed in future.

PROBLEM / SYMPTOM 1: ISOLATION.

Ellicekeeps mostly to herself, which is a symptom of her depression. It is primarily evidenced by:

1. The mum describes her as an active person when she stayed at home but,now Ellice claims to not have friends.
2. She ignores calls and texts from friends and believes they are just pretending and are not actually her friends.
3. She used to regularly visit her mum at least once a week but has not been home for over a month.

LONG TERM GOAL:

Mary will interact more with her family and friends and make new friends and gain confidence I their concern of her.

Target Date: (insert date)

SHORT TERM GOALS

1. Ellice will continue to visit home at least once a week with the goal of encouraging her to interact with people and avoid isolation (Reichenberg & Seligman, 2016).

Frequency: once per week Duration: a day to two days Progress: Plans to start soon

Target Date: (insert date) Completion Date: ______ Status: ______

Intervention:

Ellice’ mum will pick her up during the weekends to encourage her to be around family. Friends will be invited over for meals to see how she interacts with them.

2. Ellice will work with counselor to help expose and extinguish irrational beliefs and conclusions of friendship and people in general and to identify conflicts from the past and the present that form the basis that people pretend to be her friend.

Frequency: once per week Duration: for 45 minutes Progress: Working on

Target Date: (insert date) Completion Date: ______ Status: ______

Intervention:

Counselor will provide therapy to help Ellice expose and extinguish irrational beliefs and conclusions of friendship and people in general and help to developing reality based, positive thinking that will increase self-confidence and thus increasing her interaction with people. Progress will be monitored and documented.

3. Ellis will join at least one extracurricular activity

Completion Date: ______ Status: ______

PROBLEM / SYMPTOM 2: Depressed mood

Ellis depressed mood has been identified as an active problem requiring treatment (Gallagher-Michaels, 2013).It is evidenced by:

1. Complaints of Feeling Sad most times because she feels she cannot succeed in anything she does.

LONG TERM GOAL:

Ellis will report depressed mood at most once a week.

Target Date: (insert date)

SHORT TERM GOALS:

1. Ellicewill identify and understand the causes of her depressed feelings by keeping a journal where she writes her experiences whenever her mood changes. This will help Elliceunderstand her emotions and moods and understand the patterns they go through.She will share thejournal with counselor.

Duration: one month Progress: Working on

Target Date: 10/6/2016 Completion Date: ______ Status: ______

PROBLEM/SYMPTOM:Poor concentration

Ellice zones out during conversations, staring into thin air. Also, lack of concentration was the reason why she got fired.

Target date:

LONG TERM GOAL:

Ellice will learn to be in the moment and avoid distractions from her thoughts (Reichenberg & Seligman, 2016).

SHORT TERM GOALS:

1. Practice meditation

Frequency: Daily Duration: 30 minutes Progress: Working on

Target Date: (insert date) Completion Date: ______ Status: ______

STATUS:

9/22/2016: The undersigned clinician met with the patient and the mother on the date above in a face to face meeting to work with her in developing this Treatment Plan.

STRENGTHS:

Ellis has identified the following strengths:

1. Supportive family and friends. They are the ones who noticed her changes and the mother suggested therapy.
2. Religious backing. She was an active member of her home church and they even fund her studies with regular check-ups.
3. Ellice was usually very social and interacts well with others.

Preferences:

1. Ellice prefers individual therapy, a few sessions with the mother.

Signed By:

On:

References

Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) By American Psychiatric Association

Gallagher-Michaels, J. (2013). Treatment Plans and Interventions for Depression and Anxiety Disorders (2nd edn.) Robert L. Leahy, Stephen JF Holland and Lata K. McGinn New York: The Guilford Press, 2012, pp. 490.£ 50.99 (pb). ISBN: 978-1-6091864-4. Behavioural and Cognitive Psychotherapy, 41(1), 123-124.

Gintner, G. G., Parker, H. K., Ray, M. E., & LA Rouge, B. DSM-5 Has Arrived.

Koukopoulos, A., & Sani, G. (2014). DSM‐5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatrica Scandinavica, 129(1), 4-16.

Reichenberg, L. W., & Seligman, L. (2016). Selecting effective treatments: A comprehensive, systematic guide to treating mental disorders. John Wiley & Sons