This paper establishes a treatment plan through a series of steps guided by the assessment and diagnosis of a hypothetical client. Assessment data gathered from a social history, a mental health exam, and clinical interview revealed diagnosis for Military Battery and Sexual Trauma Post-Traumatic Stress Disorder (PTSD); severe depression; and low self-esteem. .
Treatment goals and objectives will be included in the treatment plan to promote healing, acceptance of past events, and deliberate living. Long and short-term goals will be realistic for the client, based on the client's strengths and limitations. Treatment modality will reflect the best possible approaches given the client's capabilities. The following treatment plan is hypothetical!.
Problem Selection and Assessment.
A 24-year-old Caucasian female veteran has a history of ambivalence about treatment. She also has a history of presenting in crisis, but recently made a commitment to participate regularly in outpatient psychotherapy for the treatment of sexual trauma, military battery, depression, and low self-worth. .
Cognitive Processing Therapy (CPT) has proven benefits in treating veterans with Post-Traumatic Stress Disorder (PTSD) which was initiated but was discontinued due to patient's inability to make weekly appointments. Other activities, including family obligations and volunteer activity often conflicted with therapy visits, but client remains motivated for therapy. .
Patient describes herself as highly competent in the past, resulting in difficulty accepting any flaws. She has a history of anger outbursts, difficulty maintaining relationships and employment. She has difficulty tolerating stress and regulating her emotions, and her mood seems to frequently vary with acceptance of others. She denied Suicidal Ideations/Homicidal Ideations at this time. .
Problem Definition and Diagnosis.
DSM-V Diagnosis:.
Axis I: Major Depressive Disorder, Post-Traumatic Stress Disorder due to Military Battery and Sexual Trauma.
