Oliver’s Treatment Plan
In the practice of clinical psychology, the ability to create a proper and thorough treatment plan
is crucial. You will write your own treatment recommendations for client Oliver. Read over his
intake summary, and then start to build a plan of action to best assist the client, without
misdiagnosing or overmedicating him. Treatment plans should be 3 body pages in length,
answering all the questions posed; double-spaced in Times New Roman font size 12, with
normal margins and no extra spacing between sentences or paragraphs. It should include a proper
APA cover page with page numbers, and in-text citations with a corresponding reference page
for any research cited (you must use at least one piece of appropriate or relevant research).
Each section title should be bolded and written in paragraphs; use full sentences and do not use
bullet points, except for the diagnostic section. The treatment plan must be written in the thirdperson narrative, so avoid the use of “I.” Work must be submitted by the indicated due date,
uploaded on Blackboard in PDF.
In your recommendations, you must explore the following areas:
Client
List the client’s name, age, height, weight, orientation, presentation, occupation, and living
situation. This can be drawn directly from the intake summary and stated as succinctly and
directly as possible.
Concerns & Problems
Here is where you will list Oliver’s symptoms (most pressing/concerning symptoms first; in
order of concern, not order as written), using the correct clinical language we learned to describe
each (translate into the appropriate clinical terminology, do not simply restate intake). Phrase
your analysis clinically and factually- “Client reports/states/experiences/demonstrates XYZ.”
Not all the symptoms may be spelled directly out for you—this task may require some applied
thinking and review of our clinical terminology for symptoms.
Supports & Strengths
List the client’s relevant positive attributes and personal strengths only, with no negative context.
Please note that they may come in several different forms. Try to identify as many positive
attributes and strengths as you can in all areas of his life.
Diagnosis: (formatted exactly as listed below, with no interpretive content)
– Primary and Secondary Clinical Diagnosis (if applicable)
– Personality Disorders and Intellectual Disability (if applicable, otherwise list N/A)
– Medical Problems (if applicable)
– Psychosocial Stressors (select from list of given categories, no rationale)
– Global Assessment of Functioning (assign one specific number within your chosen range—the
client will not squarely fit into one category; a bit of clinical interpretation will be required,
however please save your reasoning for the diagnostic rationale section).
Diagnostic Rationale
Please provide an explanation for each part of your diagnostic conclusions.
Treatment Recommendations
This should be the most elaborated section of your plan. Use this section to outline Oliver’s best
possible treatment options. Your plan should answer each of the following questions:
Is medication a recommended option? Why or why not?
If so, which category and type of medication, and specifically which medication, and why?
(Watch out for interactions- any moderate risk or greater should call for PCP monitoring in a
specified area plus any additional monitoring that is standard for that medication).
Which theoretical approach/es of psychotherapy are recommended and why?
Which specific techniques and interventions that we learned about should be used, and for which
problems/symptoms? Any supplementary therapies?
At what frequency and duration is the course of treatment recommended?
How long before a reassessment of this treatment plan?
What is the prognosis/expected outcome?
Oliver’s Intake Summary
Oliver Hayden is a 23-year-old Caucasian male, presenting at 5”11 and 172 lbs. He is
fully oriented x3. His hygiene is good. He resides in a private house with his parents and younger
brother. Oliver reports that his family gets along well, but they struggle a bit to pay their bills
each month, which causes some ongoing tension and concern. Oliver reports he would like to
address his “freaking out all the time,” which he describes as bouts of intense anxiety (but not
panic) with no discernible trigger or cause, that has been ongoing since childhood. Oliver states
he would like to learn how to control his “constant worrying.”
He has recently moved home after graduating from college with a degree in engineering
eight months ago. Oliver works at a research lab to generate income, as he has been unable to
find a job in his field. After a number of consecutive job applications didn’t lead to interviews,
he stated he believes that he is “basically worthless and unemployable—no one in my field wants
to hire me.” He was not consoled by the suggestion that his experience is relatively common. He
reports there have been no changes to his eating or sleeping, and that he continues to participate
in hobbies, like rock climbing and video games.
Oliver willingly seeks clinical assistance today, at the request of his parents, because he
reports that for the past two months, he has been hearing the research rats at his lab giving him
rude and disparaging commentary. He reports that they whisper unkind things to him when no
one else is in earshot. Oliver was unwilling to share specific examples in the interview, because
he stated that his co-workers were recording him as part of a coordinated plot to get him fired.
Oliver stated, “I can hear the Cracklebow of their Grapsters, this isn’t a good place to Zackle”
demonstrating an unusual speech pattern of made-up words.
Oliver reports he does have some close friends from college that he sees socially, but they
do not know about the rats. They have noticed, however, a change in his behavior and have
expressed concern. Oliver does not have a girlfriend currently but has dated in the past. He stated
he would one day like to marry and start a family.
Client is allergic to Penicillin. Oliver takes 10mg Zestril per day for high blood pressure,
and a multivitamin.
Psychosocial and Environmental Problems
Psychosocial and environmental problems may affect the diagnosis, treatment, and prognosis of mental
disorders. A psychosocial or environmental problem may be a negative life event, an environmental
difficulty or deficiency, a familial or other interpersonal stress, an inadequacy of social support or
personal resources, or other problem relating to the context in which a person’s difficulties have
developed. So-called positive stressors, such as job promotion, should be listed only if they constitute
or lead to a problem, as when a person has difficulty adapting to the new situation. In addition to playing
a role in the initiation or exacerbation of a mental disorder, psychosocial problems may also develop
as a consequence of a person’s psychopathology or may constitute problems that should be considered
in the overall management plan.
When an individual has multiple psychosocial or environmental problems, the clinician may note as
many as are judged to be relevant. In general, the clinician should note only those psychosocial and
environmental problems that have been present during the year preceding the current evaluation.
However, the clinician may choose to note psychosocial and environmental problems occurring prior
to the previous year if these clearly contribute to the mental disorder or have become a focus of treatment-for example, previous combat experiences leading to Posttraumatic Stress Disorder.
For convenience, the problems are grouped together in the following categories:
• Problems with primary support group – e.g., death of a family member; health problems in
family; disruption of family by separation, divorce, or estrangement; removal from the home;
remarriage of parent; sexual or physical abuse; parental overprotection; neglect of child; inadequate
discipline; discord with siblings; birth of a sibling
• Problems related to the social environment- e.g., death or loss of friend; inadequate social
support; living alone; difficulty with acculturation; discrimination; adjustment to life-cycle
transition (such as retirement)
• Educational problems – e.g., illiteracy; academic problems; discord with teachers or
classmates; inadequate school environment
• Occupational problems – e.g., unemployment; threat of job loss; stressful work schedule; difficult
work conditions; job dissatisfaction; job change; discord with boss or co-workers
• Housing problems – e.g., homelessness; inadequate housing; unsafe neighborhood; discord
with neighbors or landlord
• Economic problems – e.g., extreme poverty; inadequate finances; insufficient welfare support
• Problems with access to health care services – e.g., inadequate health care services;
transportation to health care facilities unavailable; inadequate health insurance
• Problems related to interaction with the legal system/crime – e.g., arrest; incarceration;
litigation; victim of crime
• Other psychosocial and environmental problems – e.g., exposure to disasters, war, other
hostilities; discord with nonfamily caregivers such as counselor, social worker, or physician;
unavailability of social service agencies.
Global Assessment of Functioning (GAF)
91 – 100 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand,
is sought out by others because of his or her many positive qualities. No symptoms.
81 – 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas,
interested and involved in a wide range of activities, socially effective, generally satisfied with life, no
more than everyday problems or concerns (e.g., an occasional argument with family members).
71 – 80 If symptoms are present, they are transient and expectable reactions to psychosocial stressors
(e.g., difficulty concentrating after family argument); no more than slight impairment in social,
occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
61 – 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social,
occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally
functioning well, has some meaningful interpersonal relationships.
51 – 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR
moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers
or co-workers).
41 – 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any
serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
31 – 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure,
or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment,
thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child
frequently beats up younger children, is defiant at home, and is failing at school).
21 – 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in
communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal
preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or
friends)
11 – 20 Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death;
frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g.,
smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
1 – 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability
to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.
