Case Study

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TREATMENT PLAN GOALS / OBJECTIVES

 

Note: Always make objectives measurable, e.g., 3 out of 5 times, 100%, learn 3 skills, etc., unless they are measurable on their own as in “List and discuss [issue] weekly…”

 

Abuse/Neglect

 

Goal:   Explore and resolve issues relating to history of abuse/neglect victimization

 

  • Share details of the abuse/neglect with therapist as able to do so
  • Learn about typical long term/residual effects of traumatic life experiences
  • Develop two strategies to help cope with stressful reminders/memories

 

Alcohol/Drugs and Other Addictions

 

Goal:   Be free of drug/alcohol use/abuse

 

  • Avoid people, places and situations where temptation might be overwhelming
  • Explore dynamics relating to being the [child/husband/wife] of an [alcoholic/addict] and discuss them each week at support group meetings
  • Learn five triggers for alcohol & drug use
  • Reach ____ days/months/years of clean/sober living

 

Adoption/Foster Care Placement

 

Goal:   Explore and resolve issues related to adoption/out-of-home placement

 

  • Discussongoing concerns and issues related to adoptive and/or biological parents during weekly sessions
  • Talk about his/her wishes with regard to permanency planning

 

Anger

 

Goal:   Increase and practice ability to manage anger

 

  • Walk away from situations that trigger strong emotions (100%)
  • Be free of tantrums/explosive episodes
  • Learn two positive anger management skills
  • Learn three ways to communicate verbally when angry
  • Be able to express anger in a productive manner without destroying property or personal belongings
  • Be able to express anger without yelling and using foul language
  • Explore and resolve conflict with ____ (list triggers)
  • Get through an entire day without an angry mood swing (or breaking/punching…)
  • Get through a whole week without fighting with ____
  • Take a time-out when things get upsetting
  • Learn and practice anger management skills especially in situations where people are not treating him/her respectfully

 

Anxiety

 

Goal:   Develop strategies to reduce symptoms, or

Reduce anxiety and improve coping skills

 

  • Be free of panic episodes (100%)
  • Recognize and plan for top five anxiety-provoking situations
  • Learn two new ways of coping with routine stressors
  • Report feeling more positive about self and abilities during therapy sessions
  • Develop strategies for thought distraction when fixating on the future

 

Behavior Problems

 

Goal:   Improve overall behavior (and attitude/mood), or

Maintain positive behavior (and attitude/mood)

 

  • Be free of _____ behavior
  • Develop a reward system to address ___ (target problem)
  • Learn two ways to manage frustration in a positive manner
  • Share two positive experiences each week in which X is proud of how he/she has behaved
  • Stay free of fights
  • Stay free of drug & alcohol use and abuse (100%)
  • Be free of violent behavior
  • Be able to keep hands and feet to self
  • Be able to express anger in a productive manner without destroying property or personal belongings
  • Be free of threats to self and others
  • Complete daily tasks (e.g. chores, pet care, self care, etc.)
  • Avoid leaving clothing/toys/personal stuff all around the house
  • Listen to parent and follow simple directions with one prompt
  • Put all dishes, glasses, cups, and food items back in the kitchen after meals/snacks
  • Clean up after himself/herself
  • Admit and accept personal responsibility for own actions/behavior
  • Be respectful of adults and avoid talking back
  • Get through a whole week without fighting with ____
  • Avoid behavior that would result in a loss of custody
  • Be able to play with others peacefully for ____ minutes
  • Come home each day by ______ (time)
  • Keep parents informed about where you are and when you will be home
  • Be in bed by _____ each night
  • Be free of bedwetting
  • Be free of wet/soiled underwear
  • If an accident happens, be responsible and clean it up
  • Be free of any behavior that could result in loss of job
  • Remain free of behaviors which would lead to arrest
  • Comply with all aspects of probation/parole and avoid behavior that could violate
  • Eat/swallow only items intended to be food

 

Communication Skills

 

Goal:   Learn and use effective communication strategies

 

  • Talk nice or do not say anything at all
  • Learn three ways to communicate verbally when angry
  • Be able to express anger in a productive manner without destroying property or personal belongings
  • Be able to express anger without yelling and using foul language
  • Be able to express wants and needs through spoken language
  • Be able to ask questions and tell about instances
  • Be able to stick up for self assertively
  • Speak in a clear and concise manner so others fully understand him/her
  • Learn to express feelings verbally without acting out

 

Crime

 

Goal:   Remain free of behaviors which would lead to arrest/violation

 

  • Keep working and comply with all aspects of probation
  • Be able to express anger in a productive manner without destroying property or personal belongings
  • Be free of threats to self and others
  • Comply with all aspects of probation/parole and avoid behavior that could violate
  • Be free of violent behavior
  • Stay free of drug & alcohol use and abuse (100%)

 

Decision Making

 

Goal:   Improve decision making skills

 

  • Make short and simple “to do” lists and complete three tasks each day
  • Celebrate little successes each day using positive self talk and/or journaling
  • Be able to weigh options and make simple decisions within 5 minutes
  • List three options for any major decisions and then discuss with therapist or family

 

Depression

 

Goal:   Improve overall mood

 

  • Be free of suicidal thoughts
  • Call crisis hotline if having suicidal thoughts
  • Report feeling more positive about self and abilities
  • Get 7-8 hours of restful sleep every night
  • Avoid napping/sleeping to escape other people and activities
  • Shower, dress, and then do something every day
  • Report feeling happy/better overall mood
  • Make short and simple “to do” lists and complete three tasks each day
  • Celebrate little successes each day using positive self talk and/or journaling
  • Get through a day/week without a crying spell
  • Develop strategies for thought distraction when ruminating on the past

Eating Disorders

 

Goal:   Resolve eating disorder

 

  • Eat a balanced diet of foods and maintain good overall health
  • Gain ____ pounds
  • Loose ____ pounds
  • Be free of binge eating/purging
  • Remove junk foods from home and limit future purchases
  • Recognize/list environmental and situational triggers and develop alternative behaviors for coping with them
  • Recognize emotional triggers and develop alternative ways of strategies for meeting emotional needs

 

Enuresis and Encopresis

 

Goal:   Be free of wetting/soiling

 

  • Avoid drinking near bedtime
  • Eat high-fiber foods and avoid foods that constipate
  • Go to the bathroom before going out of the house
  • Sit on the toilet for 10-15 minutes after meals
  • Avoid hiding wet/soiled clothing
  • Take responsibility for helping clean up (e.g., put wet/soiled items in soak bucket)

 

Expression of Feelings, Wants and Needs

 

Goal:   Learn appropriate ways to express different feelings

 

  • Share two positive experiences each week in which client is proud of how he/she has behaved
  • Gain knowledge of different feelings
  • Turn to adults for help when feeling sad, angry or negative feelings
  • Express feelings verbally rather than whine and/or cry about them
  • Learn to express feelings verbally without acting out

 

Family Conflict

 

Goal:   Learn and use conflict resolution skills

 

  • Recognize patterns of family conflict discuss weekly in therapy
  • Avoid angry outbursts by walking away from stressful situations
  • Get through X days out of 7 without fighting with siblings
  • Be respectful of ____: Listen, follow directions and avoid talking back
  • Be able to live together peacefully, free of all angry physical contact
  • Learn three ways to communicate verbally when angry
  • Be able to express anger without yelling and using foul language
  • Explore and resolve conflict with ____
  • Be able to stick up for self assertively, not aggressively
  • Be respectful of adults/don’t talk back
  • Get through a whole week without fighting with ____
  • Speak in a clear and concise manner so others fully understand him/her
  • Learn to express feelings verbally without acting out

 

Griefand Loss

 

Goal:   Explore and resolve grief and loss issues

 

  • Give sorrow words – discuss issues of grief weekly with therapist
  • Continue to explore and resolve issues of grief/loss as they arise
  • Get through a week without a crying spell
  • Learn about the typical 2-7 year process of grieving the loss of a loved one
  • Explore spirituality and the role it plays in redefining views about the meaning and purpose of life
  • Create (write/draw) a soul sketch of the deceased loved one
  • Plan a memorial service for the anniversary of the loss
  • Develop appropriate rituals to remember and honor _____

 

Harm to self or others

 

Goal:   Be free of thoughts of self-harm/self mutilation, or

Be free of thoughts to harm to others

 

  • Learn two ways to manage frustration in a positive manner
  • Explore triggers of thoughts to harm self or others
  • Call crisis hotline when needed
  • Report feeling more positive about self and abilities
  • Explore and resolve stress from ____
  • Develop a crisis plan and share it with key people
  • Remove weapons from the home [and other means]
  • List three emergency contacts who will be able to stay with you till a crisis passes

 

Health Issues

 

Goal:   Manage physical healthcare conditions and cope with related stress

 

  • Learn as much as possible about the condition(s) and needed treatment
  • Take medications/treatments as prescribed on a daily basis
  • Attend all scheduled appointments with the doctor
  • Maintain good overall physical health and healthcare practices
  • Report any medication concerns to the prescribing doctor ASAP
  • Seek additional advocacy services from _____
  • Seek additional support from _____

 

Hyperactivity

 

Goal:   Improve overall behavior, or

Maintain positive behavior

 

  • Be able to keep hands and feet to self
  • Complete daily tasks (e.g. chores, pet care, self care, etc.)
  • Listen to parent/teacher and follow simple directions with one prompt
  • Behave in an age-appropriate manner
  • Maintain passing grades
  • Will be able to focus attention and complete school-related tasks each day
  • Listen and take notes in all classes
  • Will review homework and other projects with parents on the day they are assigned
  • Be respectful of adults and avoid talking back
  • Be able to play with others peacefully for ____ minutes
  • Be free of any behavior that could result in detention/suspension
  • Develop a reward system to address ____ (target problem)

 

Medication Management

 

Goal:   Medication management

 

  • Take medications as prescribed on a daily basis
  • Attend all scheduled appointments with the psychiatrist
  • Maintain good overall physical health and healthcare practices
  • Report any medication concerns to the doctor ASAP

 

Mood Management

 

Goal:   Maintain stability of mood, or

Improve overall mood, or

Maintain even mood, or

Increase ability to manage moods

 

  • Learn two ways to manage frustration in a positive manner
  • Be free of suicidal thoughts; call crisis hotline if having suicidal thoughts
  • Report feeling more positive about self and abilities
  • Report feeling happy/better mood (4 days out of 7)
  • Get 7-8 hours of restful sleep every night
  • Get through a week without a crying spell

 

Parenting

 

Goal:   Improve parenting skills

 

  • Set two limits and stick with a plan that will require more responsible behavior
  • Focus on positive behavior and give attention then, rather than focus on negative things
  • Learn and be able to effectively use transactional analysis to stay in “adult” mode
  • Use “I” statements rather than You” when communicating with _____
  • Develop and consistently use a behavior modification plan, to increase/eliminate _____

Personal Hygiene and Self-care

 

Goal:   Improve personal hygiene and attentiveness to independent/age appropriate self-care

 

  • Brush teeth ____ times each day and floss _____
  • Shower (take a bath) every day
  • Use antiperspirant / deodorant every day after showering
  • Brush/comb hair every morning
  • Do a thorough job of wiping after toileting (100%)

 

Physical Health Issues

 

Goal:   Cope with stress of physical health issues and chronic pain

 

  • Explore and resolve thoughts and feelings that arise as a result of medical conditions and medications
  • Learn two new strategies for coping with the above thoughts and feelings
  • Reduce weight by _____ pounds
  • Exercise for 20 minutes every day
  • Learn strategies to advocate for him/herself with medical personnel
  • Quit smoking (or drinking)
  • Take medications as prescribed on a daily basis
  • Attend all scheduled appointments with physicians
  • Maintain good overall physical health and healthcare practices
  • Report any medication concerns to the doctor ASAP
  • Make and keep an appointment with _____ (dentist) for needed diagnosis and treatment

 

Relationships

 

Goal:   Establish/maintain civil and supportive behavior

 

  • Avoid angry outbursts by walking away from stressful situations
  • Be free of affairs
  • Be able to live together peacefully, free of all angry physical contact
  • Learn three ways to communicate verbally when angry
  • Explore peer and dating relationships to improve X’s chance of staying safe and legal
  • Be able to keep hands to self
  • Be able to express anger without yelling and using foul language
  • Explore and resolve conflict with ____
  • Be able to stick up for self assertively
  • Be respectful of parents/don’t talk back
  • Get through a whole week without fighting with ____
  • Speak in a clear and concise manner so others fully understand him/her
  • Be able to play with others peacefully for ____ minutes
  • Learn to express feelings verbally without acting out
  • Associate with healthy people and continue to make new friends
  • Continue to explore relationship issues and slowly see new opportunities for dating
  • Figure out why relationships fail and better plan for finding next partner
  • Associate with people outside of work and make one or two new friends

 

School Issues

 

 

  • Go to school every day
  • Behave in an age-appropriate manner
  • Maintain passing grades
  • Will be able to focus attention and complete school-related tasks each day
  • Listen and take notes in all classes
  • Be free of suspensions and detentions
  • Will review homework and other projects with parents on the day they are assigned

 

Self Image

 

Goal:   Explore and resolve issues related to self image

 

  • Discuss life events that led to and/or reinforce a negative self image during weekly therapy
  • Use positive self talk daily
  • Exercise daily (or _____ times per week)
  • Drop _____ pounds
  • Report feeling more positive about self and abilities
  • Return to school and work on getting _____ (degree/diploma/GED)
  • Change jobs to one that…(offers more pay and/or better suits skill set)
  • Openly discuss issues relating to sexuality and become comfortable with sexual identity
  • Explore spirituality and the role it plays in the meaning and purpose of life
  • Engage in volunteer work and/or other meaningful activity at least three hours each week

 

Sleep Problems

 

Goal:   Get 7-8 hours of restful sleep each night

 

  • Limit consumption of food and drinks before bed
  • Limit intake of caffeine (coffee, tea, soda) and chocolate after_____ (noon meal)
  • Cut back on things that may impede normal sleep patterns (e.g., alcohol and some medications)
  • Be in bed by _____ each night
  • Have 30 minutes of quiet time before going to bed each night (e.g., read, meditate)
  • Avoid overly stimulating shows/movies/video games before bedtime
  • Avoid watching TV and chatting on the phone while in bed
  • If not asleep in 20 minutes, get up and do something for a bit, rather than try to force sleep
  • Leave a paper and pen to write worries down instead of ruminating on them
  • Learn best practices for sleep (cooler room, limit caffeine, calming time before bed)
  • Listen to relaxation/meditation music to aid falling asleep

 

Social Skills

 

Goal:   Improve social skills

 

  • Speak in a clear and concise way so others fully understand him/her
  • Learn to express feelings verbally without acting out
  • Make a new same-age friend
  • Spend two hours playing with peers each week

 

Stress

 

Goal: Be able to cope with routine life stressors and take things in stride

 

  • Assess personal risk traits and resiliency traits and discuss the role each plays in coping with daily stresses during the time between therapy sessions
  • Learn two ways to manage frustration in a positive manner
  • Get 7-8 hours of restful sleep every night
  • Talk out routine stress events during weekly therapy sessions
  • Explore and resolve residual stress from ____ (e.g., years as a first responder)
  • Foster two new activities/interests that will help mitigate stress
  • Exercise 20-30 minutes per day
  • Learn and use meditation and relaxation techniques daily

 

Suicide

 

Goal:   Be free of suicidal thoughts/attempts

 

  • Explore and resolve stress from ____
  • Call crisis hotline if having suicidal thoughts
  • Develop a crisis plan and share it with key people
  • Remove weapons from the home [and other means]
  • List three emergency contacts who will be able to stay with you till a crisis passes

 

Thought Disorder

 

Goal:   Improve ability to see world as others do

 

  • Be free of false perceptions and [see/hear/smell/feel] things as others do
  • Be free of false beliefs
  • Be free of thoughts that others are out to get you
  • Spend 2-3 hours each week visiting with others
  • Visit the clubhouse and/or the consumer drop-in-center each week
  • Report feeling comfortable spending time with others

 

Trauma

 

Goal:   Explore and resolve issues related to ____ (traumatic event)

 

  • Explore and resolve residual stress from ____ (e.g., years as a first responder)
  • Share details of the trauma with therapist, as able to do so
  • Reframe negative perceptions, when possible, and focus on finding meaning and drawing strength from the event
  • Learn about typical long term/residual effects of traumatic life experiences
  • Explore spirituality and the role it plays in life after traumatic events
  • Learn about the typical 2-7 year process of rebuilding life after trauma

 

Vocational/Educational

 

Goal:   Find a new job, or Keep present job, or Re-enter the work force

 

  • Earn G.E.D.
  • Explore options for returning to school/training
  • Become an active member of a local clubhouse
  • Complete college/technical school
  • Develop a resume
  • Seek two people who will serve as references
  • Be free of any behavior that could result in loss of job/educational grants
  • Find and settle into a new job

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12/10/09 jdw

 

TREATMENT PLAN INTERVENTIONS (FOCUSING ON: ______)

 

 

  • Acceptance (of limitations/reality)
  • Accountability
  • ACOA Issues
  • Anger Management (e.g., punch bag/pillow)
  • Art Therapy
  • Assertiveness Training
  • Behavior Modification (e.g., rewards)
  • Best Practices for ____ (e.g., better sleep)
  • Bibliotherapy
  • Building on Strengths
  • Career Counseling
  • Coaching
  • Cognitive-Behavioral Therapy
  • Communication Skills
  • Community
  • Conflict Resolution
  • Couples Therapy
  • Crisis Planning
  • Defusing/Debriefing
  • Dignity/Self-worth
  • Discipline
  • Drug & Alcohol Referral
  • Education (e.g., graduation/GED)
  • Empathy
  • Empowerment
  • Encouragement
  • Expression of Feelings
  • Fair Fighting Skills
  • Family Therapy
  • Feedback Loops
  • Forgiveness
  • Gestalt Therapy
  • Getting a Job (Better Job)
  • Goal Planning/Orientation
  • Good Choices/Bad Choices
  • Good Touch/Bad Touch
  • Gratitude
  • Grief/Loss/Bereavement Issues
  • Homework Assignments
  • Humility
  • Increasing Coping Skills
  • Independence
  • Journaling
  • Letting Go
  • Life Skills Training
  • Listening
  • Logical Consequences of Behavior
  • Magic Question (3 wishes/magic wand)
  • Making Friends
  • MISA/MICA Issues (Dual Dx Treatment)
  • Modeling Appropriate Behaviors
  • Money Management
  • Monitoring of _____
  • Motivation
  • Narrative Therapy
  • Normalization
  • Parent Effectiveness Training/Skills
  • Partializing (breaking down goals into manageable pieces)
  • Patience
  • Perseverance
  • Personal Hygiene
  • Play Therapy
  • Portion Control (Weight Control)
  • Positive Self-talk
  • Primal Screams
  • Priority Setting
  • Practice Exercises
  • Processing _____ (e.g., guilty feelings)
  • Psychodrama
  • Psychoeducation
  • Reality Therapy
  • Recognizing _____ (e.g., self destructive patterns of behavior)
  • Refer to ______
  • Reframing
  • Rehearsal
  • Relapse Prevention
  • Relationship Issues
  • Relaxation Techniques (e.g., breathing)
  • Responsibility for Actions
  • Role Playing
  • Self-care Skills
  • Self-direction (Independence)
  • Sexual Identity Issues
  • Sexuality
  • Solution-focused Therapy
  • Spiritual Exploration
  • Starting Over
  • Stop-Think-Act
  • Strength Focus/Listing
  • Stress Inoculation
  • Stress Management
  • Supportive Relationships
  • Talk Therapy
  • Therapeutic Stories & Worksheets
  • Timeouts
  • Transactional Analysis (P-A-C)
  • Trigger Recognition
  • Twelve Step
  • Socialization
  • Social Skills Training
  • Social-Vocational Training
  • Values Clarification
  • Verbal Communication Skills
  • Weight Control/Loss
  • Workbooks

 

 

 

 

 

10/7/09 revision/jdw