Running Head THERAPEUTIC PROCESS2THERAPEUTIC PROCESS.docx

Running Head: THERAPEUTIC PROCESS
2
THERAPEUTIC PROCESS 3
Therapeutic Process
Lori Ann Wright
Grand Canyon University: PCN 610
August 21, 2019
Running head: ASSIGNMENT TITLE HERE
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Running head: THERAPEUTIC PROCESS
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Therapeutic Process
Part 1
Stella is a 40-year-old woman who is my client. Her eyes are
expressionless as she gives an apology for being late for her
appointment. On asking her where she was coming from she
states that she had gone to see her nephew whom she had taken
a few of her electronics she no longer thought she needed and
he was better placed to use them. While she appears and admits

to still being sad even after letting go of her electronics, she
states that the sadness does not compare as to how she felt when
she still had the items in her possession. Stella is recently
divorced and had lost custody of her two children after being a
stay at home mom for more than ten years.
It has been three months since her divorce and contrary to her
wishes, we try avoiding talking about her divorce. We discuss
her teenage children’s achievements over the years that she
believes she contributed greatly. Mark is an achieving athlete
while Ann plays the piano with talented mastery. This however,
reminds her that she lost custody and her face is filled with the
hopelessness we have been trying to help her see is not
necessary. She states that she sees no need to continue living
without her children whom she has been forced to stay states
away from. Upon her divorce and loss of custody, she has had to
move back to her parents’ as being unemployed she could not
afford to live on her own. She explains she gave up accounting
12years ago to be a hands-on mom and upon inquiring whether
she would like to go back to it she starts sobbing unstoppably.
Since our time was moving fast, there was little we could do
amidst her sobs and I chose to let her cry as many tears as she
could. After calming down she stated that all she knows how to
do is take care of her children’s needs by preparing their meals,
attending their games and play sessions, and tend to them when
they were sick. At this point, she breaks down into tears stating
that there was really no need to keep acting strong as she was
feeling very weak and unable to take it all in. it is at this point
that I notice the marks on her wrists.
Part 2
I believe that, Stella Matthew could potentially be a
suicidal patient whom as much as they have not stated the need
to end their life, exhibits symptoms and behaviors of one who
has, or is about to start having suicidal thoughts. One of the
reasons to believe so are her explicit mood changes and extreme
sadness, while she is okay one minute she could be sobbing the
next and avoiding eye contact or refusing to talk completely in

the other minute (Panagioti et al, 2012). For instance, in this
session, she kept sobbing and at some point she refused to
continue talking citing that she was tired from having taken the
electronics to her nephew and getting rained on.
In addition, she has a general sense of hopelessness that can
easily be noted not just from looking at her but also from what
she keeps saying. According to her, she dedicated all her life
raising and catering to the needs of her children and now that
she can no longer do that she does not know what to do and sees
no meaning in fighting or even existing. The gravest symptoms
in addition to all this is the fact that she has been cutting her
wrists whenever the sense of hopelessness overwhelms her and
that is one of the things she refuses to talk about.
Part 3
The minute I started being concerned about Stella’s possibility
of being suicidal, I asked her the following questions so I could
gauge her level of risk at hurting herself or ending her life. The
first question was whether she had found herself wishing she
didn’t have to wake up in the morning or wishing she were dead
to which she replied in the affirmative. This I followed up with
whether she ever had any thoughts of ending her life or had a
plan in which she would do so, to which she nodded, looking
away and avoiding my eyes.
She said that she cut herself in the shower when no one else
could hear her sob in pain as she let the shower run while she
did so. She believed that if she did that enough she would
eventually bleed out in her sleep. She added that she thought
this was taking more time than she had and even thought of
adding sleeping pills to the exercise when she was alone in the
house. Her thoughts appeared well planned out and ended up
answering the third, fourth and fifth question together
(Silverman & Berman, 2014). She has not only thought of
ending her life but has attempted it on several occasions, only
that she has been lucky enough to not succeed nor be found out.
For whether she has started working out the plan to end her life
she stated that she knew that her parents would be travelling to

visit her sister soon and she planned to use the time she would
be alone to take some pills and cut both her wrists so she could
bleed out in their absence. This would reduce the risk of anyone
finding her before she finally went to her end and would make
things easier as she would not have to explain to anyone why
she took that route. According to what Stella has reported she
has started self-harming and is planning on doing more self-
harm to herself. The first time she attempted suicide by cutting
her wrists was two days ago.
From the questions asked, it is quite clear that Stella is at high
risk for suicide, and if action is not taken she may even be
tempted to re-attempt taking her life sooner than she states.
Considering how hopeless she feels and how frequently she
keeps falling into her bouts of hopelessness, action needs to be
taken. On a scale of 1 to 10 she is a possible 9.5 and the first
thing to do is ensure she is not left alone (Sullivan & Bongar,
2009). Getting her an extensive clinical suicide assessment,
brief suicide safety assessment, after which she should be
admitted in a mental health facility under strict monitoring.
This would then require that her parents who she currently stays
with are immediately informed and should also receive some
counseling however brief, on how to handle her.
In addition to documenting all she says verbatim in the
assessing and reassessing sessions, it is important that anything
that could possibly give her a chance to self-harm should be
kept away from her, talking to her parents could help with this.
Also reconstructing her therapy sessions to help her see the
positive things she has going on currently and giving her ideas
for life, other than just helping her get over her divorce should
be helpful.

References
Panagioti, M., Gooding, P. A., & Tarrier, N. (2012).
Hopelessness, defeat, and entrapment in posttraumatic stress
disorder: their association with suicidal behavior and severity of
depression. The Journal of nervous and mental
disease, 200(8), 676-683.
Silverman, M. M., & Berman, A. L. (2014). Suicide risk
assessment and risk formulation part I: A focus on suicide
ideation in assessing suicide risk. Suicide and Life‐Threatening
Behavior, 44(4), 420-431.
Sullivan, G. R., & Bongar, B. (2009). Assessing suicide risk in
the adult patient.
Running head: : treatment plan
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treatment plan

Eliza’s Treatment Plan
Lori Ann Wright
Aug 12, 2019
Treatment theories guide counselors and therapists to
illuminate a patient's behavior, feelings, and thoughts, which
aim them in diagnosis, treatment, and post-treatment. These
theories are integrated with theoretical approaches in the whole
therapeutic process. However, counselors, as well as therapists,
face the problem of identifying the counselling theory that
would work best for a particular client. Treatment theories are
the specific theories that provide the ingredients necessary for
guiding a patient to recovery. They are capable of creating a
clinical change to a patient. Treatment theories do not state the
impact or the extent of the change. Treatment theories are
critical in the treatment of mental disorders, especially in the
early stages of treatment. This research analyzes the treatment
theory that would be suitable for Eliza's treatment based on her
symptoms. The cognitive theory would be used in Eliza's
treatment.
Cognitive Theory
The cognitive-behavioral theory is the most suitable for Eliza's
treatment process because it plays a central role in restructuring
cognition. Eliza's negative thinking, which causes anxiety,
might have played a role in her depressive condition, and
therefore, cognitive modification may be necessary to alter her
cognitions (Hawley et al., 2017). The theory suggests that
cognitive therapy replaces unsound cognitive content with
unbiased content. Moreover, cognitive therapy works by helping
patients to regard their negative thoughts as just mental events.
It would, therefore, help Eliza to distance herself from the
negative thoughts that make her anxious. It would reduce the

impact of negative emotions on her. During cognitive therapies,
the therapist asks her patient to view what she thinks as a
hypothesis that is not yet tested and not a reflection of reality.
The DSM-5 diagnostic criteria showed that Eliza had five major
depressive symptoms which included little interest or pleasure
in doing usual activities, little enjoyment of social activities,
slight sleeping problems, anxiety, as well as lack of identity
(Schwitzer & Rubin, 2014). Cognitive behavioral therapy would
be critical for Eliza to help improve the symptoms of
depression. The goals or objectives of the treatment include (a)
anxiety reduction. (b) Reducing her sensitivity to traumatic
experiences. (c) Maintaining abstinence from alcohol and
marijuana. (d) Increasing coping skills. (e) Stabilizing and
adjusting to new life experiences. (f) Improving self-worth as
well as relationships. (g) Mood stabilization.
Cognitive Behavioral Therapy (CBT) treatment plan would help
reduce Eliza's anxiety problems by decreasing the excessive
fearful feelings that she develops when interacting with her
friends, who often take advantage of her. Eliza would be guided
on how to normalize her emotions by recognizing the behaviors
or pattern of thoughts that trigger anxiety (Segal & Teasdale,
2018). CBT would help Eliza to manage any maladaptive beliefs
that negatively affect her emotions, thereby interfering with her
mood. CBT would also be critical in assessing Eliza's way of
thinking and try to modify it to avoid erroneous beliefs
(Thompson et al., 2018).
Cognitive therapy can be as effective as antidepressants in the
treatment of mild as well as moderate depression, which is the
case of Eliza. However, when a combination of antidepressants
and cognitive therapy is used, the course of treatment can be
shortened by reducing depressive symptoms such as low self-
esteem and loss of energy (Segal & Teasdale, 2018). Cognitive
therapy would help Eliza start feeling and thinking better.
Cognitive therapy may be the most suitable alternative
treatment method for depression since it is able to influence an
individual's mood, which is associated with most depressive

symptoms.
Eliza had some traumatic experiences in high school,
where her friends teased her. These experiences may have
played a part in her condition. Cognitive therapy helps patients
to come over traumatic experiences by changing their
perception towards those activities (Thompson et al., 2018).
Besides, Eliza has had problems making new friends after
separating with her high school friends. Her depressive
condition has instilled fear in hear since she doesn't recognize
her worth. CBT would modify Eliza's dysfunctional feelings,
emotions, and behaviors to help her understand the feelings and
thoughts that affect her behavior.
The counselor would direct that Eliza be monitored to ensure
that she stays away from substance use since it can affect her
recovery. Research shows that depression patients may get into
substance abuse to manage their condition. Depression patients
abuse substances to get away from the negative thoughts and
feelings that they experience. It would also be critical to advise
Eliza about the importance of abiding by the rules and
regulations of any institution to avoid punishments can affect
the feelings and thoughts of an individual. Possession and
consumption of alcohol are illegal in Eliza's college.
Conclusion
Cognitive behavioral therapy is a widely used method used in
the treatment of depression. Although almost everyone has
negative feelings and thoughts, depression is caused by extreme
negative thoughts. Cognitive therapy is, therefore, critical
because it helps patients avoid excessive negative emotions,
thoughts, and feelings. It helps them to overcome thoughts that
take over their body and interfere with their view of reality.
Cognitive therapy for depression acts is an effective way of
diffusing negative thoughts, and when used over a period of
time can change how individuals suffering from depression see
things.

References
Hawley, L. L., Padesky, C. A., Hollon, S. D., Mancuso, E.,
Laposa, J. M., Brozina, K., & Segal, Z. V. (2017). Cognitive-
behavioral therapy for depression using mind over mood: CBT
skill use and differential symptom alleviation. Behavior
therapy, 48(1), 29-44. doi: org/10.1016/j.beth.2016.09.003
Schwitzer, A. M., & Rubin, L. C. (2014). Diagnosis and
treatment planning skills: A popular culture approach (2nd ed.).
Los Angeles, CA: Sage Publications. ISBN-13: 9781483349763
Segal, Z. V., & Teasdale, J. (2018). Mindfulness-based
cognitive therapy for depression. New York: Guilford
Publications.
Thompson, K., Schwartzman, D., D'Iuso, D., Dobson, K. S., &
Drapeau, M. (2018). Client and Therapist Interpersonal
Behavior in Cognitive Therapy for Depression. Canadian
Journal of Counselling & Psychotherapy/Revue Canadienne de
Counseling et de Psychothérapie, 52(3), 3, 229-249.
Running head: Depression disorder
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Depression disorder
Screening, Diagnosis and Treatment of Depression Disorder

Lori Ann Wright
August 6, 2019
Screening, Diagnosis and Treatment of Depression Disorder
Depression is a mental disorder that has both social and
health effects to individuals worldwide. Reports from the WHO
suggest that depressive disorders form a significant percentage
of the total number of deaths reported in both developed and
developing countries. Depressive disorders are also a major
cause of disability (U.S. Department of Health, 2017).
Depression is treatable. The commonly used treatments of
depression include psychotherapy and drugs. Studies suggest
that there are various effective strategies available for use to
improve the depression symptoms such as the integration
between specialist and primary health care. The severity of
depression varies from patient to patient. DSM-5 is the
commonly used diagnostic criteria used to differentiate
depressive disorders from sadness (Gore & Widiger, 2013). The
criterion was developed in the United States and has been used
extensively in psychiatric research. The model stipulates the
threshold that the signs and symptoms of depression must meet
to justify a diagnosis. This research analyzes Eliza Doolittle’s
psychosocial assessment and treatment plan.
Intake
Eliza Doolittle is an eighteen years old girl. Her residence at the
time of the visit was a school dormitory where she lived with
her friends. Eliza stated the reason for her visit was due to
being sent home from school. The depressive symptoms that
Eliza experienced were anxiety or stress and low self-esteem.
Eliza is the only child in her family. Her father is Burt, and her
mothers name is Joan. She denied being on any medication for
mental health at this time. She also added that she had not
encountered any stressful experiences in her life.
Eliza completed the DSM-5 Self-Rated Level 1 Cross-Cutting
Symptom Measure (CCM-1) for adults, which is a questionnaire

with the various depressive symptoms. This questionnaire
enables the healthcare professional to identify the depressive
symptoms that Eliza might have had in the last two weeks
before her visit. According to the DSM-5 diagnostic criteria,
Eliza must have experienced at least five symptoms of
depression in the same two weeks period. Eliza must have at
least one of the following symptoms to warrant a diagnosis.
These include: loss of pleasure in usual activities, loss of self-
worth or suicidal, fatigue, weight loss, tiredness, inability to
think correctly, loss of energy and loss of appetite.
Biopsychosocial Assessment
Eliza was identified as a Caucasian female who was a first-year
college student studying engineering. Eliza’s parents live in a
town, which is about two hours away from the health center.
Eliza was sent to counseling because she was found with
alcohol in the dormitory although she claimed she was not
intoxicated. However, she said that she was drunk. Eliza said
that she had been experiencing stress in school since things in
college were not easy as they were in high school. She added
that study requirements have been difficult in college. Eliza
stated that making friends had been difficult for her since her
high school friends either went to different colleges or pursued
other things.
Eliza admitted that she had used substances such as alcohol, and
marijuana, although she said that she has never overused any of
the substances. The only type of addiction that Eliza has was
online gaming. Besides, she denied having been previously
hospitalized due to mental illness. Eliza has had traumatic
experiences, although she stated that she was teased in high
school. Eliza’s social relationships were questionable because
she felt that her friends were misusing her on many occasions.
However, she had a good relationship with her parents despite
there being some strains between the parents. Her family rarely
goes to church; therefore, she is not strictly spiritually aligned.
Eliza denied having had suicidal or homicidal intentions.
Assessment of Eliza’s symptoms using the DSM-5 diagnostic

criteria showed that Eliza had experienced five depressive
symptoms in the last two weeks prior to her visit to counseling.
The symptoms included little pleasure or interest in doing
normal activities, anxiety, slight sleeping problems, lack of
identity, and little enjoyment of social activities. The CCM-1
results show that Eliza has slight symptoms of depression,
which if not managed, can easily become more severe if the
causes are not well managed. According to the DSM-5
diagnostic criteria, the results suggest that Eliza has mild
depression because she had experienced at least one diagnostic
symptom that is a loss of pleasure in usual activities.
The initial treatment goals for Eliza would be directed towards
improving the depressive symptoms that Eliza has experienced.
The major depressive symptoms in Eliza’s life are the loss of
interest in normal activities as well as anxiety. There is no
standard treatment for mild depression. However, Eliza has
several options available for her treatment. First, the symptoms
of mild treatment can go away without being treated. The
physician can allow Eliza to go and come back after two weeks
to check whether the situation will have improved (Schwitzer &
Rubin, 2014). This method is commonly referred to as watchful
waiting. Secondly, the physician can advise Eliza to start doing
exercises. Exercise has been identified as one of the effective
methods of dealing with mild depression (Schwitzer & Rubin,
2014). The physician can decide to involve Eliza in a group
class where they will be doing exercises together. Third, self-
help is a method of treating mild depression where Eliza would
think about her feelings by talking to a psychological therapist
or a friend.
Treatment Planning
APA offers a number of measures that help in the
assessment of patients. The assessment measures should be
administered form the first interview with the patient to help

monitor the progress of the treatment (Weiner & Greene, 2017).
DSM-5 Level 2 of assessing depression are used to measure the
progress that Eliza would be taking during treatment. Eliza
would require CCM-2 to measure her level of anxiety in the
first seven days of treatment (Weiner & Greene, 2017). Eliza
would be required to fill the CCM-2 questionnaire, which
contains eight items whereby she would be needed to rate the
severity of the depression in the last seven days. The physician
then interprets the data and determines the level of depression
of Eliza.
Apart from the assessment provided by APA, Eliza can
use online self-assessment tests to monitor her progress,
especially with the issue of anxiety. Anxiety was the major
problem that Eliza highlighted as a point of concern. She used
to avoid anxious situations to manage her condition (Bot et al.,
2017). Online assessments include questions similar to those of
other assessments tests. The patient is required to give genuine
information to be able to give genuine results. This process is
helpful, especially if the patient has to travel for a long distance
to see the physician.
The findings of the assessment should be conveyed to
Eliza in her native language. Diagnostic information should be
provided in a language that Eliza understands best. The
physician should maintain clear communication with Eliza
(Gilligan et al., 2018). Clear and improved communication
reduces the chances of adverse events by managing the anxiety
of the patient. Although there is no standard way of
communicating assessment results to Eliza or her family, the
physician should be keen to avoid chaos. Communication failure
can be disastrous (Gilligan et al., 2018). The physician should
be able to tell the patient the situation is under control.
The objective of the physician is to guide the patient
through the journey to a healthier state. The outcomes of the
treatment are dependent on not only the prescription of the
physician but also on Eliza’s willingness the get well and
thereby follow the instructions. If the patient misses

appointments or drops-out of the psychological therapies, it may
be difficult for the physician to deliver the agreed-upon
outcomes. However, patient follow-up helps keep the patient on
track. Strategies, measures, and outcomes are achievable when
the relationship between the Eliza and the clinician is
maintained.
Referral
Referrals are necessary when the clinician cannot offer
the services needed by Eliza. The clinician can request the help
of other professionals who can assist in the treatment process
(Russomagno & Waldrop, 2019). If the needs of the client are
outside the expertise of the clinician, a referral would be made.
Examples of referrals in mental illnesses include psychological
therapists, psychiatrists, family therapists, and mental health
nurse. The referrals would be necessary for Eliza to help her
understand her feelings. Therapists would allow her to cope
with the symptoms of depression.
The choice of referrals depends on the inherent
condition that requires the expertize of other professionals.
Eliza would require a psychological therapist who would enable
her to understand the feelings that are depressing her
(Russomagno & Waldrop, 2019). One can clearly see that Eliza
feels that she is alright and doesn’t need any mental care.
However, since the DSM-5 criteria showed that her experiences
meet the criteria, it is necessary for her to get treatment. For
this reason, a psychological therapist would help her understand
the feelings and situations that make her depressed.
Conclusion
Despite the overwhelming evidence on the prevalence of
depression around the world, there are just a few studies that
provide information on its treatment. Furthermore, treatment of
mild depression is not sufficiently researched, although some
studies propose various methods. However, there is one
common feature in all depressive disorders; that is, the patient
follows up. The therapeutic approach that was highlighted as a

possible treatment plan requires the clinician to constantly
follow-up the progress of Eliza. The study also pointed out the
importance of referrals in the treatment of depression.
References
Bot, M., Middeldorp, C. M., De Geus, E. J. C., Lau, H. M.,
Sinke, M., Van Nieuwenhuizen, B., ... & Penninx, B. W. J. H.
(2017). Validity of LIDAS (Lifetime Depression Assessment
Self-report): a self-report online assessment of lifetime major
depressive disorder. Psychological medicine, 47(2), 279-289.
DOI: https://doi.org/10.1017/S0033291716002312
Gilligan, T., Coyle, N., Frankel, R. M., Berry, D. L., Bohlke,
K., Epstein, R. M., ... & Nguyen, L. H. (2018). Patient-clinician
communication: American Society of Clinical Oncology
consensus guideline. Obstetrical & Gynecological
Survey, 73(2), 96-97. doi:
10.1097/01.ogx.0000530053.40106.9b
Gore, W. L., & Widiger, T. A. (2013). The DSM-5 dimensional
trait model and five-factor models of general
personality. Journal of abnormal psychology, 122(3), 816. Doi:
org/10.1037/a0032822
Russomagno, S., & Waldrop, J. (2019). Improving Postpartum
Depression Screening and Referral in Pediatric Primary
Care. Journal of Pediatric Health Care, 33(4), e19-e27.

doi.org/10.1016/j.pedhc.2019.02.011
U.S. Department of Health & Human Services, (2017). HIPAA
for Professionals. Retrieved from
https://www.hhs.gov/hipaa/for-professionals/index.html
Weiner, I. B., & Greene, R. L. (2017). Handbook of personality
assessment. New York, NY: John Wiley & Sons.
Psychosocial Assessment
____ Part 1 (Topic 2)
Template
Name:
______________________________ Date: _________________
DOB: ________________
Age: ________________________________ Start Time:
____________ End Time: ___________
Identifying Information:

_____________________________________________________
_______________________________ David is a 49 years old
man. He is married with two children. He has been working in a
steel mill as a metallurgical engineer for 20 years.
Presenting Problem:
David has lost interest in doing the things he used to do such as
watching TV, attending family gatherings, and playing golf, and
instead spends a lot of time in his bedroom alone. He has lost
appetite and also doesn’t sleep well. He doesn’t feel the need
for living anymore but believes he will recover from this sour
mood.
Life Stressors:
David’s sister’s condition may have contributed to his condition
since she has been struggling with depression for 10 years.
Substance Use: FORMCHECKBOX
Yes FORMCHECKBOX
No
_____________________________________________________
_______________________________ David has had a problem
with alcohol abuse. He drinks more at night because he has
sleep disturbances.
Addictions (i.e., gambling, pornography, video gaming)
David has a problem with alcohol addiction. However, he has
changed his drinking patterns and takes two to three drinks perf
night unlike previously when he used to drink frequently.
Medical/Mental Health Hx/Hospitalizations:
David hasn’t sought help previously from any healthcare
facility in regard to this condition.
Abuse/Trauma:

David doesn’t have major traumatic events. However, Lisa’s
condition may have traumatized him.
Social Relationships:
David has for the last 6 months withdrawn himself from family
gatherings and mostly spends time in solitude.
Family Information:
David has not lost any member of his family. However, losing a
family member can be traumatic and lead to depression.
Spiritual:
David does not give any information about his spiritual
inclinations. However, spirituality can be a cause of mental
health problems as well as recovery.
Suicidal:
David admits that he feels that life isn’t worth living.
Therefore, it is most likely he is suffering from depression.
Homicidal:
David does not show any signs of violence towards his friends
and family, or threatening or attempting to kill them.
Assessment:
Assessment is done to determine whether David is depressed or
not. If yes, it should establish the level of depression he is in.
Depression can be mild, moderate, severe or the symptoms can
be subthreshold depressive (Maj, 2013). First, subthreshold
depressive disorder would occur in case David exhibits fewer
than five symptoms of depression. This is always the first stage
of depression. Second, mild depression requires David to
exhibit more than five symptoms of depression. In this case,
David would have a minimal functional impairment. Third,
moderate depression means David would have significant
functional impairment although the symptoms would not be

severe. Fourth, severe depression is diagnosed if David has
most of the symptoms of depression (Maj, 2013). In this case,
the symptoms would be capable of interfering with David’s
functioning.
Initial Diagnosis (DSM):
The DSM-5 Diagnostic Criteria of depression outlines that if
David has experienced five or more symptoms of depression at
the same time in a period of two weeks with at least one of the
signs being loss of pleasure or interest, David is likely to be
suffering from depression (Maj, 2013). The critical signs
highlighted in the DSM-5 model are (1) loss of pleasure or
interest in normal activities, increased or decreased in appetite,
slowing down of physical movement and thought, loss of energy
or fatigue, feelings of worthlessness, indecisiveness, and
suicidal thoughts (Maj, 2013). David has been experiencing
most of the symptoms highlighted by the DSM-5 model. David’s
symptoms are, therefore, sufficient to warrant a depression
diagnosis.
Initial Treatment Goals:
The symptoms that David has experienced in the last two
months shows that he has been suffering from moderate to
severe depression. The following treatments are recommended
for the treatment of depression.
1) Antidepressants - These are tablets used to treat
depression symptoms. There are various
types of antidepressants that are available for use by David.
2) Combination therapy - David can be prescribed to use a
combination of antidepressants and therapy. This combination
of treatments works better than using only one type of treatment
(Davidson, 2010). David may be referred to a mental health

support team which may be a psychiatrist, occupational
therapist, specialist nurse, or a psychologist for counseling
while at the same time taking antidepressants.
Therapists provide the following talking treatments to patients
with moderate to severe depression like David.
(a) Cognitive-behavioral therapy (CBT). The aim of CBT is to
help a patient to understand their behavior and thoughts that
affect them. CBT takes a period of 10 to 12 weeks with 6 to 8
sessions when David would spend time one-on-one with a
counselor (Davidson, 2010).
(b) Psychodynamic psychotherapy. David can be assigned a
psychodynamic therapist to encourage him to give more
information about his thoughts to find out whether there are
hidden patterns that are influencing his behavior (Davidson,
2010).
(c) Counseling. Counseling can help David solutions of how to
deal with the problems he is facing. The counselor would give
David practical advice within 6 to 12 sessions of counseling.
Plan:
Due to the severity of David’s symptoms, he will be required to
start taking paroxetine antidepressants immediately. Paroxetine
is a type of Selective serotonin reuptake inhibitors (SSRIs) that
are recommended for they help improve the mood of a patient
through a natural chemical known as serotonin. David will also
be required to attend therapeutic sessions. He will be seeing the
doctor once a week to assess his progress. If David responds
well to the medication, he will continue with the same dose of
paroxetine. If there are no changes in the symptoms of David,
the doctor will change the medication and prescribe a different
antidepressant such as Vortioxetine. During the period of

medication, David may have some side effects such as dry
mouth, headaches, and nausea. However, the side effects should
improve with time.
Name: _____________________________________________
Date: __________________
References
Davidson, J. R. (2010). Major depressive disorder treatment
guidelines in America and Europe. The Journal of clinical
psychiatry, 71, e04-e04. DOI: 10.4088/JCP.9058se1c.04gry
org/10.1037/a0032822
Maj, M. (2013). “Clinical judgment” and the DSM‐5 diagnosis
of major depression. World Psychiatry, 12(2), 89-91. doi:
org/10.1002/wps.20049
Template

Name:
______________________________ Date: _________________
DOB: ________________
Age: ________________________________ Start Time:
____________ End Time: ___________
_____________________________________________________
Presenting Problem:
mood.
Life Stressors:
Yes FORMCHECKBOX
No
_____________________________________________________
sleep disturbances.

Abuse/Trauma:
Family Information:
Spiritual:
Suicidal:
Homicidal:
Name: _____________________________________________

Date: __________________
References
org/10.1037/a0032822
Template
Name:
______________________________ Date: _________________
DOB: ________________
Age: ________________________________ Start Time:
____________ End Time: ___________
_____________________________________________________

Presenting Problem:
mood.
Life Stressors:
Yes FORMCHECKBOX
No
_____________________________________________________
sleep disturbances.
Abuse/Trauma:

Family Information:
Spiritual:
Suicidal:
Homicidal:
Name: _____________________________________________
Date: __________________
References
org/10.1037/a0032822

Treatment Plan
Based on the information collected in Week 4, complete the
following treatment plan for your client Eliza. Be sure to
include a description of the problem, goals, objectives, and
interventions. Remember to incorporate the client's strengths
and support system in the treatment plan.
Client: Eliza Doolittle
Date: 8/13/2019
Age: 18 DOB:
8/1/2001
DSM Diagnosis
ICD Diagnosis
GENERALIZED ANXIETY DISORDER
300.02
Goals / Objectives:
Interventions:
Frequency:
□ Mood Stabilization
□ Psychotropic Medication Referral & Consultation □
Journaling
□ Cognitive Behavior Therapy □ Skill Training
□ Emotion Recognition – Regulation Techniques
□ Weekly □ Bi Weekly □ Monthly
□ other: ____________________
□ Group □ Individual □ Family
□X Anxiety Reduction
Journaling

X□ Relaxation Techniques
□X other: 1 x per day
□ Group □X Individual □ Family
□ Reduce Obsessive Compulsive Behaviors
Journaling
□ other: ____________________
□ Decrease Sensitivity to Trauma Experiences
□ Verbalize Memories Triggers & Emotion
□ Desensitize Trauma Triggers and Memories
□ Utilize Healing Model/Support (Mending the Soul)
□ other: ____________________
□ Establish and Maintain Eating Disorder Recovery
□ Overcome Denial □ Identify Negative Consequences
□ Menu Planning □ Nutrition Counseling □ Body Image Work
□ Healthy Exercise □ Trigger Mngmt Recovery Plan □ CBT
□ other: ____________________
□X Maintain Abstinence from substances (Alcohol/Drugs)
□X Substance Use Assessment □ Stepwork □ Overcome Denial
X□ Identify Negative Consequences □ Commitment to
Recovery Program □ Attend Meetings □ Obtain Sponsor
X□ other: 1 X
□X Increase Coping Skills
□ DBT Skills Training □X Problem Solving Techniques
□ Emotion Recognition & Regulation X□ Communication Skills

X□ other: DAILY
X□ Stabilize, Adjustment to New Life Circumstances
□X Alleviate Distress □X Cognitive Behavior Therapy
□ Stress Management □ Skills Training
X□ Improve Daily Functioning X□ Develop Healthy Support
□X other: 1 X DAILY
□ Group □X Individual X□ Family
□ Decrease/Eliminate Self Harmful Behaviors
□ Cognitive Behavior Therapy □ Skills Training
□ Develop and Utilize Support System
□ other: ____________________
□X Improve Relationships
□X Communication Skills □ Active Listening □X Family
Therapy X□ Assertiveness □X Setting
Healthy Boundaries
□ other: ____________________
□ Group X□ Individual □X Family
□X Improve Self Worth
X□ Affirmation Work □X Positive Self Talk X□ Skills
Training
□X Confidence Building Tasks
□X other: 1 X DAY
□ Grief Reduction and Healing from Loss
□ Psychoeducation on Grief Process/ Stages
□ Process Feeling □ Emotion Regulation Techniques
□ Reading/Writing Assignments □ Develop/Utilize Support
□ other: ____________________

□ Develop Anger Management Skills
□ Decrease Anger Outbursts □ Emotion Regulation Techniques
□ Cognitive Behavior Therapy
□ Increase Awareness/Self Control
□ other: ____________________
© 2017. Grand Canyon University. All Rights Reserved.

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