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Creating a Treatment Plan for PTSD: What to Include + Example

Experiencing trauma is, unfortunately, something that many individuals experience at some point in their lives.. Normative reactions to traumatic events include shock, fear, sadness, anxiety, difficulty sleeping, and intrusive thoughts or memories related to the events, all of which tend to resolve over time. When these symptoms are persistent, or worsen over time, the individual may have developed post-traumatic stress disorder (PTSD), which usually required treatment from mental health professionals. Keep reading to learn how you can create an evidence-based treatment plan for PTSD and what you should include (with an example).

The exact prevalence of PTSD is unknown because there has yet to be a survey asking every U.S. resident about their trauma history and related mental health concerns. The research we do have estimates that about 6% of the U.S. population will experience PTSD during their lifetime. It is believed that 5% of the U.S. population is living with PTSD every day, which is approximately 13 million individuals. Women are more likely to develop PTSD when compared to men who experience traumatic events. Additionally, Veterans are at a higher risk of developing PTSD when compared to civilians, especially those who are deployed to a war zone

Setting Goals and Objectives With Clients in Your PTSD Treatment Plan

 When you begin thinking about PTSD treatment plan goals for your client, it is important to reflect on the information you have gathered in previous sessions. More specifically, their current symptoms and their severities, as well as how these symptoms are affecting their functioning.  This will give you insight into what goals would be impactful, as well as realistic, for your client at this point in their journey. It will be important to consider the presence of other mental health concerns, including substance use disorders, depression, anxiety, dissociative disorders, and personality disorders, as these too should be addressed within a treatment plan. 

Clinicians who provide treatment for PTSD tend to have a theoretical approach that they gravitate towards, which they have likely received training and supervision for. There are several evidence-based approaches that can be used for treating PTSD, some of which can be used in a group or individual setting. The following theories have clinical evidence demonstrating their effectiveness in reducing PTSD symptoms:

What to Include in a Treatment Plan for PTSD + Example

For the remainder of this resource, we will elaborate on various components of a PTSD treatment plan example that will use CPT as its treatment modality. With this, we will be craft components of a treatment plan that aligns with the following case study:

Jane is a 28-year-old female who was referred to counseling after a follow-up appointment with her primary care physician. Jane survived a car accident 4 months ago where she was hit by an impaired driver while driving her 4-door sedan. She experienced serious physical injuries, and was in her local ICU for a couple weeks to manage her conditions. After her release, she was referred to physical therapy and her primary care physician for further treatment. She has been attending physical therapy as scheduled, and feels as though she is making progress in that regard. Her primary care physician has discontinued her use of pain medications, and referred her to a mental health treatment provider for her continued psychological distress. Symptoms discussed in her intake session included intrusive thoughts and memories of the accident, flashbacks, nightmares, being startled easily, irritability, and poor concentration. Jane cannot drive because of her physical injuries, and she avoids being in cars when possible. She reported feeling more comfortable when traveling in a larger vehicle, such as an SUV or pickup truck because it is never safe to drive in cars. At this point, Jane’s symptoms have been present for over 3 months, and have significantly impacted her ability to attend appointments, focus on work, and complete day-to-day tasks. She has also reported relationship distress with her partner, noting that she does see her irritability as a common thread in their arguments.

View our Counseling treatment Plan that corresponds with this resource or view all of our Trauma Worksheets

Agencies Involved and Plans for Care Coordination

 When we look at Jane’s case, it would be appropriate to be in contact with her primary care physician, as they were the referral source. Your contact could be as brief, or descriptive as you deem necessary, and Jane is comfortable with. Based on the symptoms described, Jane may be a suitable candidate for Psychotropic medications, which means that a referral to a psychiatrist may be warranted.

Example for Jane:

Other Agency: Primary Care Physician

Plan to Coordinate Services: Call XXX-XXXX to verify information reported in session, follow up as needed

Other Agency: Licensed Psychiatrist (referral)

Plan to Coordinate Services: initiate referral for evaluation based on reported PTSD symptoms

Clinical Diagnoses

Based on the information provided, it sounds as though Jane is experiencing PTSD. Her car accident was an experienced trauma which caused serious injuries, resulting in a hospital admission. She endorsed intrusive symptoms, negative cognitions, avoidance of stimuli related to the accident, and changes in arousal and reactivity.

There are a number of clinical assessments that can be used during an assessment to screen for PTSD as well as formulate a diagnosis, and track changes in symptoms, including:

  • Clinician-Administered PTSD Scale (CAPS)
  • PTSD Checklist for DSM-5 (PCL-5)
  • Impact of Event Scale-Revised (IES-R)
  • Davidson Trauma Scale (DTS)
  • Post-traumatic Stress Disorder Checklist (PCL-C)
  • Trauma Symptom Inventory-2 (TSI-2)
  • Harvard Trauma Questionnaire (HTQ)

Example for Jane:

  • Post-Traumatic Stress Disorder, 309.81
  • Supporting Assessments: PCL-5 score of 56

Current Medications and Responses

At this time, Jane is not currently taking medications, as her primary physician ended her pain medication prescription recently. If you provide a referral to a psychiatrist, this area could be updated to reflect changes that occur in Jane’s medication regimen. 

Example for Jane:

None at this time/ N/A/ N/A/ N/A

Presenting Problem and Related Symptoms

This area of your treatment plan will provide a detailed account of Jane’s symptoms, and the effect that they have been having on her overall level of functioning.

Example for Jane:

Client has indicated the presence of intrusive thoughts and memories, flashbacks, nightmares, being startled easily, irritability, and poor concentration, since being in a traumatic vehicle accident that resulted in serious physical injuries. Avoidance symptoms are present, as she avoids being in smaller care. Her level of functioning has been impaired, and she struggles with her concentration and focus, and is experiencing interpersonal challenges, which she attributes to her mental health.

Goals and Objectives

Identified goals often require long-term focus and commitment, which should also be realistic, attainable, and specific. Objectives are smaller, or short-term goals, that fall under the scope of overarching goals on a treatment plan. Breaking larger goals down into digestible sections can make them feel more manageable and less intimidating for clients. 

Examples Jane:

Goal 1:

Problem/Symptom: Intrusive Symptoms

Long-Term Goal: Improve ability to identify, modify, and cope with intrusive symptoms

Objective 1: Jane will learn to identify and challenge maladaptive thoughts related to the traumatic event(s) during therapy sessions.

Objective 2: Jane will practice using cognitive restructuring techniques to reframe intrusive memories and flashbacks, reducing their frequency and intensity.

Objective 3: Jane will develop and implement coping strategies, such as grounding techniques or guided imagery, to manage distressing intrusive symptoms outside of therapy sessions.

Goal 2

Problem/Symptom: Avoidance Behaviors

Long-Term Goal: Decrease arousal resulting from triggers that cause avoidance behaviors

Objective 1: Jane will create an avoidance hierarchy, ranking avoided situations or triggers related to the traumatic event(s) from least to most anxiety-provoking.

Objective 2: Jane will gradually confront avoided situations or triggers in a controlled and systematic manner, using exposure techniques during therapy sessions.

Objective 3: Jane will monitor and challenge avoidance behaviors outside of therapy sessions, gradually increasing engagement in avoided activities or situations over time.

Goal 3:

Problem/Symptom: Negative thoughts and beliefs affecting emotions and behaviors

Long-Term Goal: Modify Negative Beliefs and Thoughts

Objective 1: Jane will identify and record negative beliefs about themselves, others, and the world related to the traumatic event(s) during therapy sessions.

Objective 2: Jane will critically evaluate and challenge negative beliefs using evidence-based cognitive restructuring techniques, such as examining evidence for and against the beliefs.

Objective 3: Jane will practice adopting more balanced and adaptive beliefs about themselves, others, and the world outside of therapy sessions, reinforcing positive changes through daily journaling or self-reflection exercises.

Specific Interventions to Be Used

In Jane’s case, it is important to be mindful of evidence-based approaches for her symptoms and the goals she is working towards. This example treatment plan will utilize CPT as its therapeutic approach, with tailored interventions, specific to Jane’s needs. 

Example for Jane:

Intervention/Action: Psychoeducation about trauma and PTSD

Responsible Person: Counselor A

Intervention/Action: Socratic Questioning

Responsible Person: Counselor A

Intervention/Action: Use of Thought Records

Responsible Person: Jane

Intervention/Action: Decatastrophizing

Responsible Person: Counselor A

Intervention/Action: Relaxation techniques including, but not limited to, deep breathing, progressive muscle relaxation, and guided imagery

Responsible Person: Counselor A

Family Involvement

Social support is a common component of biopsychosocial assessments, which would allow you to identify individuals in her life that are supporting her through this challenging time in her life.

Example for Jane:

Jane wishes to involve her partner and is open to the use of joint sessions to focus on healthy communication and improving the status of their relationship. 

Additional Services and Interventions

Additional services would include other interventions used to provide whole-person care. This could include support groups, or couples counseling with her partner if she was agreeable to do so. 

Example for Jane:

  • Provide Jane with a referral for local PTSD support group
  • Provide Jane with referral to a psychiatrist for assessment of symptoms, and exploration of possible psychotropic medications

Estimation for Completion

The time frame associated with CPT falls between 12 and 16 weeks, as this is a structured and time-limited treatment approach. Counseling sessions may occur weekly or bi-weekly, and the duration of care would be dependent on the severity of Jane’s symptoms. 

Example for Jane:

12 weeks; can be adjusted if needed

Aftercare Plans

Aftercare plans should be included in a treatment plan as a safety measure in case she ends her therapeutic alliance by terminating, for any reason. Aftercare plans can be updated during treatment plan review, to reflect progress and changes in symptoms.

Example for Jane:

  • Referral for licensed therapist, psychologist, or psychiatrist
  • Local treatment centers that specialize in PTSD treatment
  • Community Mental Health Treatment Centers
  • Local support groups for PTSD

Final Thoughts On Creating a Treatment Plan for PTSD

Thank you for reading this resource on creating a treatment plan for PTSD. Trauma therapists are compassionate and supportive clinicians, devoting their time to creating a safe and supportive environment promoting healing for the individuals they work with. Evidence-based treatment approaches have been proven effective, and often provide clinicians with flexibility to adjust care to fit the needs of their client. TherapyByPro provides Treatment Plan Templates that can be used with clients who have an array of mental health concerns, including PTSD.

TherapyByPro is an online mental health directory that connects mental health pros with clients in need. If you’re a mental health professional, you can Join our community and add your practice listing here. We have assessments, practice forms, and worksheet templates mental health professionals can use to streamline their practice. View all of our mental health worksheets here.

View our Counseling treatment Plan that corresponds with this resource or view all of our Trauma Worksheets

Resources:

Kayla Loibl, MA, LMHC
Author: Kayla Loibl, MA, LMHC

Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression, anxiety, bipolar disorder, borderline personality disorder, and trauma.

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