Jamess Treatment Plan

1. Identify precipitating problems or symptoms

James is a 55 year old architect who is seeking help for his depression. He describes himself as
having been constantly angry the world for years. James believes that as a result, 6 months ago he
had a heart attack followed by triple bypass surgery. James has been twice married. He was abusive
to his first wife, as he used to have an explosive temper and often became violent. James has no
relationship or contact with his 3 adult children. They have nothing to do with him as he made no
effort to visit or keep in contact with them since after his divorce. His second marriage also failed after
only a year. Since his near death experience, the client has felt overcome with regret and sorrow for
the things he has done in his past. His two goals for therapy are recovering from his depression and
contacting and making amends with his children.
2. Conduct a comprehensive biopsychosocial assessment/history

James is in his early 50s and 6 months ago experienced a heart attack followed by a triple bypass
surgery. Since his surgery, he has quit smoking his 3 packs of cigarettes daily, and as has also cut out
the greasy cheeseburgers that he ate 4 times a week. Both of his parents are diseased. Although his
father had a history of alcohol abuse, this has not been an issue for James. No other family mental
illnesses were mentioned. This is Jamess first time in counseling. The client is experiencing deep
feelings of depression. He described himself as having felt angry at the world for years. He has a
history of losing control of his anger. Jamess explosive temper lead to him physically abusing his first
wife and afterwards shamefully ostracizing himself from his family. He hated himself for his actions and
spent long hours at his job keeping himself away from them. After his first marriage, James became
very lonely and married a younger woman who was a stripper in order to fill the void. He tried to be a
father figure to her son as he felt it was a second chance for him to be a father, but this was difficult for
him. Throughout this marriage, James felt sexually intimidated by this young woman and often felt as if
he was not pleasing her. After a short year, James was single again and did not maintain a relationship
with his stepson. James does not mention a social life. Since his heart attack and surgery, he has been
overcome with feelings of regret about his past and has decided to make changes in his personal life.
James is also feeling very regretful about not having a relationship with his 3 children. Since his heart
attack, he has become concerned with finding and trying to build some sort of relationship with them.
MSE- N/A (not in class)

Candace Thompson

Winter 2014

3. Identify individual and relationship functioning

The clients strengths are his awareness and acknowledge of his mistakes and changes that he needs
to make, as well as his self-control and determination that have helped him to make a few big changes
on his own already. James has cut unhealthy foods out of his diet, and has gone from smoking 3 packs
of cigarettes daily to none at all. He appears very committed to making several positive personal
changes in his life and getting over his depression. The clients weaknesses are his depression and
deep regret which is causing him to be stuck dwelling on his past. One of his most evident
weaknesses is his ability to maintain relationships both romantically, and with his children. He is twice
divorced and currently is not romantically involved in any relationships. He neglected his wife and
children during his first marriage and has made no effort to keep in contact with them. The client even
expressed that he hated both of his parents, who are now diseased, which indicates he most likely
didnt have much of a relationship with them either.
4. Integrate client assessment and observational data to form a conceptualization

The client's presenting complaint of depression has several contributing factors. The most significant
causal factor are his feelings of regret and shame for the things he had done in his past leading up to
his heart attack and triple bypass surgery. His feelings of hate and resentment towards his parents for
how his father treated his mother whom never left his father, could be the reason why he was often full
of anger and had trouble controlling his temper. Before his heart attack, James seemed to have a
negative view of the world as evidenced by his statement that he spent years constantly angry at the
world. The absence of a positive relationship between James and his parents could also be why he
was never able to develop relationships with his children. His second attempt as a father to his
stepson during his second marriage was also unsuccessful. The way he abused his wife reminded him
of his father, which caused him to hate himself and distance himself even more from his family. James
seems like a very lonely person who distances himself from getting too close to anyone. The clients
second marriage only lasted for a year and he has not mentioned being romantically involved with
anyone since. His lack of a social life also indicates he is very detached from people. Evidenced by the
way he stayed away from his first family and by the way he felt like he wasnt pleasing his second wife,
it appears that James feels inadequate and has low self-esteem. Now that he has been given a
second chance at living after his heart attack, James is bombarded with the realization of all of his
mistakes and self-destructive behaviors. Although, he has made a few big changes, he still may feel
hopeless in regards to mending relationships with his children. Overall, Jamess feelings of shame and
regret about his past, his loneliness and lack of relationships, and his feelings of inadequacy are all
contributing to his depression.

Candace Thompson

Winter 2014

DSM Code #
311

Candace Thompson

Diagnosis
Unspecified Depressive Disorder

Winter 2014

DSM Code #
311

Justification for Diagnosis

Fatigue and feelings of worthlessness and excessive guilt are present, but the
onset and duration of symptoms are unknown

ACTION PLAN
Long Term Goal.
Develop healthy cognitive patterns and beliefs about self and the world that lead to alleviation of depressive symptoms and
return to normal effective functioning

CHARACTERISTICS/OBSERVATION/JUSTIFICATION FOR THIS GOAL: The clients overwhelming feelings of regret and
sorrow have put him into a deep depression. Efforts to improve his mood and function will help him overcome this.

WHAT (Short Range Goal)

WHO IS RESPONSIBLE

Find ways to alleviate depressed mood and improve daily

functioning

Client and therapist

HOW (Support/Intervention)
1: Further explore current and past experiences with depression by assessing current and past mood episodes
including their features, frequency, intensity, and duration.
2: Assist the client in developing coping strategies for feelings of depression (i.e. more physical exercise, less
internal focus, increased social involvement etc.)
3: Evaluate the clients possible need for psychotropic medications and arrange for a psychiatric assessment.

CHARACTERISTICS/OBSERVATION/JUSTIFICATION FOR THIS GOAL: One of the clients goals is to reestablish

relationships with his children, and his loneliness and lack of interpersonal relationships is contributing to his
depression.

WHAT (Short Range Goal)

WHO IS RESPONSIBLE

Develop healthy interpersonal relationships that lead to alleviation

Candace Thompson

Client and therapist

Winter 2014

of depression symptoms

HOW (Support/Intervention)
1: Encourage the client to attend social gatherings, to try and meet to people and develop new friendships and
relationships.
2: Assess the clients interpersonal inventory of important past and present relationships and evidence of potentially
destructive or depressive themes.
3: Role play with client what he might say to his children when he gets in contact with them, and assist him in
coming up with ways he can reestablish relationships with them.

CLINICAL PRACTICE

Determine and identify other services that could meet the clients needs
Meeting with a psychiatrist to assess need for psychotropic medication is essential. Dating websites or attending
social gatherings may also help meet clients needs.

Identify and discuss applicable ethical and legal issues

Therapist needs to assess the possibility of suicide, considering suicidal ideation or any previous attempts.

Discuss the scope of practice parameters and any foreseen limitations

Consult with colleagues for ideas to help meet clients needs. Be aware of any transference or
countertransference.

Candace Thompson

Winter 2014

Candace Thompson

Winter 2014