Case Study Treatment Plan

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Indiana Wesleyan University, Marion *

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533

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Psychology

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Feb 20, 2024

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Treatment Plan Client Name: Joseph (Last Name not given) Case #: N/A Date: June 8, 2023 Summary of Presenting Problem(s): Client feels disoriented with new routine. Client is experiencing a change in lifestyle from working in academia to now being retired. Client reports feeling anxious about his new schedule which appears to be less filled. Client is experiencing anxiety when thinking about going out and meeting new people in the community. Client feels an increase in anxiety when he is around other people. Client has experienced an increase in these feelings gradually over the last few months. Client has mentioned previous anxiety when teaching but has found an ability to cope with the anxiety. Client is experiencing an increase in negative thoughts about his age and growing older. Client reports intrusive thoughts about being disabled. Client reports feeling trapped and not wanting to leave the house. Client reports relief when he was secluded away from other people. Client mentions feelings of hopelessness about his life being what he expected it to be. Client reports feeling judged or looked at by other people when being out in public. Provisional Diagnosis: Generalized Anxiety Disorder (F41.1) Justification for Diagnosis: Client mentions a decline in physical symptoms. Client has excessive worry about traveling to places outside of his home. Client is having trouble controlling his fear of being disabled and negative thoughts about retirement. Client has worry about his everyday life and his work. Client experienced anxiety while working in academia but had the ability to work through it. Client has increased worry about his health, specifically hearing and vision. Client experiences difficulty in feeling relieved unless he is at home or away

from people. Client mentions he does not know what is going on with him. Client mentions that he feels judge when going into public yet, did not feel judged by students when speaking just anxious. Service Plan Problem Statement Goals/Objectives 1. Experiencing negative thoughts about growing older. 1. Work on challenging fears and negative cognitions about growing older. Write down something every day he looks forward to for tomorrow. 2. Feels trapped and only feels safe at home. 2. Talk to a friend or family member about discomfort. Take a walk 2x a week in his neighborhood. 3. Feels increased judgment by others when being in public. 3. Utilize cognitive restructuring to examine his thoughts and beliefs and report a decrease in maladaptive thoughts. 4. Disoriented with a new routine and increased anxiety with a less filled schedule. 4. Use the 5 senses grounding technique to focus on the here and now. Take time for meditation. 5. Thoughts of hopelessness about future plans and retirement. 5. Practice mindfulness and staying in the present. Utilize journaling to write down potential future plans. 6. Decline in physical symptoms and feelings. 6. Increase ability to manage physical tension and anxiety. Deep breathing, exercise, and

relaxation techniques. 7. Increased anxiety when being around other people or thoughts of going out in public. 7. Work on coping skills and managing daily life stresses. Treatment Recommendations and Rationale: - Counselor will help identify and challenge dysfunctional beliefs about self-doubt and abilities with aging. - Counselor will emphasize through exposure understanding negative patterns associated with traveling and being in public. - Assist Joseph in developing a new way of coping and understand specific triggers to the public anxiety. - Counselor will help identify and challenge dysfunctional beliefs about retirement and growing older. - Counselor will facilitate Joseph in making the association that comes from trauma experience and lead to conscious and unconscious representations. - Identify ways to increase physical activity and work through an open schedule to help plan activities Joseph can do. - Assist Joseph in behavioral changes and help recognize his negative associations/ triggers with the retirement. - Referral to a psychiatrist if medication is warranted, consult with grief groups, and local trauma groups. - Give references for community based support groups for anxiety disorders. Signatures: Client(s): Date:

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Counselor(s): Date: Supervisor: Date:

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