Sean Sandag

CNS 770
Client Map Treatment Plan
Winifred
Diagnosis
300.02 Generalized Anxiety Disorder, excessive worry more days than not (especially
about school), lasting more than 6 months, possibly with social anxiety disorder.
Rule out anxiety disorder due to another medical condition.
Rule out substance/medication-induced anxiety disorder.
Rule out posttraumatic stress disorder.
Rule out depressive, bipolar, and psychotic disorders.
Rule out body dimorphic disorder.
Rule out separation anxiety disorder.
Consider unipolar depressive disorder.
Objectives
Reduce current anxiety and worry symptoms.
Reduce stress.
Address automatic thoughts and behaviors.
Reduce frequency of absences and leaving school early.
Address use medications.
Address substance use.
Address relationships at school and home.
Address possible depressive symptoms.
Address possible past traumatic events.
Teach relaxation techniques and ways to cope.
Refer to community mental health practitioner with ability to prescribe medication.
Discuss benefits of counseling concurrent with medication to treat disorder.
Assessment
Summary- 14-year-old female initially visited Student Services reporting inability to deal
with stress. She called her mom in the bathroom to pick her up from school. Her mom
refused and the student broke down in tears feeling unable to return to class. She
complains of feeling tense, worried, and unable to concentrate in class. She sleeps in
many of her classes and has consistently called home to leave school. There is no known
past diagnosis of anxiety or depression in the familys medical history. The student is not
currently prescribed any medication. There is no other past mental health diagnosis.
Students family is comprised of her mom, dad, and younger sister (age 11).
Discuss overall lifestyle and sleeping patterns.
Discuss previous attempts to manage anxiety.
Attain parental permission to administer assessments.
Administer Penn State Worry Questionnaire.
Administer Beck Anxiety Inventory.
Consider administering PHQ-9 to assess comorbid disorder of depression.
Benefits of assessment instruments: Assessments stated are very brief and easily
attainable. A client already feeling fatigued is less likely to show resistance to these
assessments (15 questions compared to tests consisting of hundreds of questions). The
questions have potential for discussion of important information.
Refer to physician for medical evaluation to rule out medical conditions that could
explain irritability and fatigue.
Clinician Characteristics
Continue to build rapport through empathy, unconditional positive regard, and
genuineness.
Be consistent. Keep appointments and follow through with agreements.
Use elicit, provide, elicit model to provide information to client that might normalize
the disorder.
Consider brief self-disclosure of personal experience with anxiety.
Acquire various techniques for coping with anxiety.
Maintain positive attitude.
Exhibit collaborative effort, we are in this together attitude.
Never give up.
Location of Treatment
See student in counselors office in Student Services during non-core classes.
Interventions to be used
Relaxation techniques such as deep breathing, guided imagery, and muscle relaxation.
Client is more likely to experience anxiety symptoms when physiologically aroused
(Leahy, Holland, Stephen, McGinn, Lata,. 2011). Controlling physiological symptoms
could reduce anxious thoughts.
Mindfulness training- client can recognize anxious or automatic thoughts as just
thoughts (Leahy, Holland, Stephen, McGinn, Lata,. 2011).
Cognitive-behavioral therapy- 6 to 8 sessions- analysis and modification of cognitive
distortions (Seligman and Reichenburg, 2012). Enable client to look at anxious thoughts
in a different way. CBT teaches clients skills to overcome deficits in emotional and
cognitive processing and can use them in forms of exposure exercises (Fresco, Mennin,
Heimburg, and Ritter, 2013).
Consider Emotion Regulation Therapy. Consists of four phases: Phase I: Awareness
Skills Training, Phase II: Regulation Skills Training, Phase III: Experiential Exposure to
Promote New Contextual Learning, Phase IV: Consolidating Themes and Looking Ahead.
ERT focusses on motivational dysfunction while expanded emotional regulation skills
(Fresco, Mennin, Heimburg, and Ritter, 2013). This may provide the student with skills
needed to function at school and control emotions to avoid break downs or the need to
sign-out of school. ERT implements aspects of CBT, Affective Therapy, Acceptance and
Commitment Therapy (ACT), and Behavior Therapy which were all discussed by
Seligman and Reichenburg (2012).
Continue supportive therapy- maintains rapport; builds trust.
Emphasis of Treatment
Focus on strengths- what has the client been doing to effectively manage anxiety?
Supportive- show empathy and desire to understand.
Collaborative- the client and counselor work together to develop plans. Ultimately, the
client knows what is best in terms of what is working for her. Focus on what she is doing
now and what she can plan in the future.
Moderately Directive- Socratic questioning to help dispute cognitive distortions.
Focus on thoughts and behaviors.
Numbers
Individual therapy primarily
Consider needs assessment to identify other students in school that may be suffering from
anxiety. Consult with teachers and administration. If others are identified, group therapy
may be efficacious by normalizing condition. The client may feel supported in knowing
she is not alone.
Consult with family. Psychoeducational family therapy may be helpful to develop
understanding.
Timing
Moderate pace- Meet weekly during school hours based on availability of school
schedule. Utilize availability of teacher assistant period and time during non-core class.
Due to block scheduling (1 hour and 30 minute class period), client may be able to meet
up to 50 minutes (depending whether the client will meet during a teacher assistant
period). Client may be able to meet last 30 minutes of non-core class depending on
curriculum.
Meet for at least 9 weeks (1 intake session and 6-8 CBT sessions). Extend duration if
group therapy is found feasible.
Continue maintenance bi-monthly or as client needs.
Medications needed
Consider referring to outside mental health practitioner for use of SSRI if comorbid
symptoms of depression are indicated (Baldwin, Khalil, Ajel, & Garner, 2008). Monitor
suicidal ideation if SSRI is prescribed.
Benzodiazepines may be helpful for short-term use (Baldwin, Khalil, Ajel, & Garner,
2008).
Do not consider medication unless anxiety is severe.
Adjunct Services
Exercise and yoga- Although limited research has proven the efficacy of exercise and
yoga to treat anxiety disorders, positive results have shown these activities as superior to
placebos (Saeed, Antonacci, and Bloch, 2010). This may serve the client as a way to
acquire energy and manage stressors in a healthy manner.
Consult with teachers to provide her with passes to leave class and come to Student
Services when she is unable to cope with anxiety symptoms.
Planned pleasurable activities- reserve at least an hour a day to do something the client
enjoys.
Prognosis
I would tell the parents of the child that I am completely confident the student will be
able to mitigate the symptoms of her diagnosis. There is substantial empirical evidence
that shows the efficacy of CBT in treating Generalized Anxiety Disorder. The student has
many strengths. She has the support of her family, teachers, and counselor. Having
support and knowing people care has also shown to have therapeutic benefits. I would
commend her for seeking help because evidence shows that many people with GAD fail
to treat their diagnosis. I believe she will gain invaluable skills through therapy that will
be beneficial to her development, especially at her age. The diagnosis becomes more
complicated if she has a comorbid disorder of depression. This may extend time of
treatment, but the diagnosis is still completely curable. She could see some relief of
symptoms as early as two weeks through therapy, medication, or a combination of both.









References
Leahy, Robert L., Holland, Stephen J. F., & McGinn, Lata K. (2011). Treatment Plans and
Interventions for Depression and Anxiety Disorders (2
nd
edition). New York: Guilford
Publications. Retrieved from http://www.eblib.com
Seligman, L., & Reichenburg, L.W. (2012). Selecting Effective Treatments- A Comprehensive,
Systematic Guide to Treating Mental Health Disorders (4
th
edition). Hoboken, NJ: John
Wiley & Sons, Inc.
Fresco, D., Mennin D., Heimburg, R., Ritter, M. (2013). Emotion Regulation Therapy for
Generalized Anxiety Disorder. Cognitive and Behavioral Practice, 20(3) 282-300.
Baldwin, D., Ajel, K., Garner, M., (2008). Anxiety Disorder. Medicine, 36(8) 415-421.
Saeed, S., Antonacci, D., Bloch, R., (2010). Exercise, Yoga, and Meditation for Depressive and
Anxiety Disorders. American Family Physician 81(8) 981.