Current Treatment Goals/Plan

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Current Treatment Goals/Plan
During the second session with my client, we discussed the goals she would like to accomplish during our time. The client’s general goals were to “be normal” and to “control my symptoms”. The client described being normal as being “off medication” and to “not focus on my problems in sessions.” She would like to be more active in the community by volunteering and exploring career options without jumping into “how can I spend the money.” An overall goal for the client is to also be better with time management and organization.
Controlling her symptoms included different facets of her symptoms and ideas about her life. Jennifer wanted to decrease her “depressive symptoms”, work on emotion regulation, and find ways …show more content…
Typically, the client wears loose fitting and colorful shirts and blue jeans with sneakers. She is of average stature and would be considered obese under a body mass index. Her clothing choices, though appropriate, tend to be disheveled. Jennifer appeared to have normal grooming and hygiene habits, however in some sessions, her teeth and hair appeared to be neglected. Speaking for her posture, the client was typically displaying a normal posture however she became tense in times where she discussed her past trauma. Motor activity appeared unremarkable and within normal ranges. The client had normal eye contact and rarely displayed avoidance. Her facial expressions were responsive in sessions. She displayed facial expressions congruent with her described moods of anxiety, sadness, depression, and anger when she explained experiences in her life and her thought content. The client’s attitude in our sessions have been cooperative. She has, to this point, been open to talking about her life and working on the skills or worksheets presented in session. The client has also been dramatic describing problems related to her landlord or eating out at restaurants. At this point, the rapport between the client and I has been stable.
Mood and …show more content…
She has never displayed a rapid or slowed rate of speech, her volume has remained consistent and had never been unusually loud or hushed and the client had appropriate quality of language and fluctuations in tone that suggested an above average comprehension of the English language. The client reported being bi-lingual, stating Spanish as a second language. This clinician cannot speak to her fluency in Spanish outside of the client translating a few sentences from life stories to help understand the content of situations. The client reported no hallucinations or delusions of any kind. She described no auditory or visual hallucinations, commanding or otherwise, and reported no grandiose or persecutory delusions. Her thought rate appeared appropriate as evidenced by her ability to properly think through questions and relay information back in sessions. She logically and sequentially could connect ideas and organize them clearly and the connections were not disjointed and easy to follow as evidenced by her ability to understand her diagnoses and build her treatment plan.
Executive
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