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Hypothetical Treatment Plan


             Axis II: No diagnosis.
             Axis III: Hypertension.
             Axis IV: Moderate problems with primary support group and untreated physical and sexual trauma. .
             Axis V: 41.
             Strengths and Limitations.
             Patient's Strengths .
             Patient is in a long-term stable relationship living in stable housing and possesses ability to function successfully in volunteer settings. She is able to meet her own active daily living obligations, including driving to and from appointments. She also has impeccable will to overcome adversity.
             Patient's Limitations.
             She has a history of failed relationships including her family of origin. She has unresolved sexual and physical trauma. This veteran has a difficult time assessing her own value. She has poor commitment to mental health despite recent efforts. She lacks effective coping mechanisms with episodic rage.
             Problem Selection and Assessment One.
             This wounded warrior becomes so frequently agitated by others her blood pressure becomes elevated then she becomes even more irritated. She becomes irate when she sees people relaxing and carrying on without a care or perceived threat in the world because she no longer can. She just recently made the observation to her spouse, "I do not understand how you can wear headphones all the time especially when watching movies. She said, "I sure as hell can't do that with my PTSD because I am constantly scouring and listening for danger." Her husband, also with a diagnosis of PTSD replied, "I wear the headphones to make it all stop." .
             Goals of Treatment.
             The veteran and counselor discussed the autonomic interactions between our thoughts, emotions, and impulses within our stress system. For victims of unresolved trauma they are on high alert all the time keeping them on their defenses. After such conversation, the veteran decided on the following short-term goals and objectives.
             Short-Term Goals.
             1. Discover coping skills, including problem solving and emotional regulation of anger.


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