Treatment Plan Example 1: Depression and social anxiety
Adult client starting outpatient CBT after intake.
- Clinical Assessment
- Client is a 34-year-old female presenting with symptoms consistent with Major Depressive Disorder, recurrent, moderate (F33.1) and Social Anxiety Disorder (F40.10). Reports persistent low mood, social withdrawal, and avoidance of work presentations for 6+ months. PHQ-9: 14 (moderate). GAD-7: 12 (moderate). No prior psychiatric hospitalizations. Currently taking sertraline 50mg prescribed by PCP. Motivated for treatment and has good insight into symptoms.
- Long-Term Goals
- 1. Reduce depressive symptoms to mild range (PHQ-9 < 10) within 6 months. 2. Client will participate in work presentations and social gatherings without avoidance within 4 months. 3. Client will develop and consistently use a repertoire of coping skills for mood and anxiety management.
- Short-Term Objectives
- 1. Client will identify and challenge 3 negative automatic thoughts per week using cognitive restructuring within 30 days. 2. Client will complete behavioral activation schedule with minimum 5 pleasant activities per week within 30 days. 3. Client will practice graduated exposure to social situations, completing 2 exposures per week within 60 days. 4. Client will report using at least 2 coping skills independently when experiencing anxiety within 45 days.
- Interventions
- 1. CBT: Cognitive restructuring to address negative automatic thoughts and core beliefs related to worthlessness and social evaluation. 2. Behavioral Activation: Structured activity scheduling to counter withdrawal and anhedonia. 3. Exposure therapy: Graduated exposure hierarchy for social anxiety situations. 4. Psychoeducation: Education on depression/anxiety cycle, cognitive distortions, and the relationship between thoughts, feelings, and behaviors. 5. Skills training: Relaxation techniques (PMR, diaphragmatic breathing) and mindfulness exercises.
- Progress Indicators
- 1. PHQ-9 administered biweekly, target reduction of 5+ points within 3 months. 2. GAD-7 administered biweekly, target reduction to mild range within 3 months. 3. Client self-report on thought diary completion and exposure exercises. 4. Behavioral tracking of social engagement and pleasant activities. 5. Treatment plan review scheduled every 90 days.