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

Trauma is an emotional response that often occurs as a result of an event, or series of events, that can be described as emotionally disturbing or life-threatening.  Trauma can be a pervasive experience, touching many different areas of your client’s life, including their mental, physical, emotional, and spiritual well-being.

Trauma is also an individualized experience in the sense that two individuals, such as siblings, can experience the same situations, stressors, and environments, yet not have the same mental health concerns resulting from the same trauma. Examples of experiences that are known to be traumatic include:

  • Emotional, physical, and sexual abuse, as well as neglect
  • Living with someone who is struggling with an addiction
  • Sudden or unexpected separation from parents, guardians, or other loved ones
  • Poverty
  • Racism, discrimination, and oppression
  • War and terrorism
  • Natural disasters including tornadoes, earthquakes, and Tsunamis

Trauma, unfortunately, is more common than we may initially think. The key thing to remember here is that everyone responds differently to traumatic events, which may be a factor contributing to limited awareness of how common traumatic experiences are. Individuals who experience trauma at a younger age are at a higher risk for experiencing long-term effects of trauma.

Adverse childhood experiences (ACEs) are a term used to describe traumatic events that occur as a child, that have lasting implications including mental health conditions, chronic diseases, substance abuse, and a reduced life expectancy. Research has indicated that 62% of adults in the U.S. have experienced at least one ACE and that a quarter of the adult population has experienced 3 or more. When we experience trauma as a child, our brains are affected, and can later struggle to respond to situations that are typical and not threatening. These effects can help us understand why trauma survivors struggle with emotion regulation, anxiety, and depression.

Traumatic experiences are a precursor for post-traumatic stress disorder (PTSD), though this is not a causation relationship. Treatment options for trauma resemble that of PTSD and vary across different levels of care, ranging from inpatient treatment options to outpatient care, allowing for individualized and comprehensive care. Treatment can include individual therapy, group therapy, support groups, educational sessions, medication management, and holistic treatment methods. Therapeutic approaches that can be used when working with clients who have a history of trauma include:

Setting Goals and Objectives With Clients in Your Treatment Plan for Trauma

As you work towards developing your trauma treatment plan, we encourage you to be mindful of the level of care that would best suit your client. As we mentioned above, trauma can contribute to a number of mental health conditions, many of which can be managed on an outpatient basis, depending on the severity of symptoms. Individuals who are a risk to themselves or others, should receive an evaluation from a higher level of care to further assess safety concerns.

There are several assessments that you can use to explore your symptoms related to trauma, including depression and anxiety. This includes:

  • Clinician-Administered PTSD Scale (CAPS)
  • Trauma Symptom Inventory (TSI)
  • Adverse Childhood Experiences (ACE) Questionnaire
  • Beck Depression Inventory (BDI-II)
  • Patient Health Questionnaire
  • Hamilton Depression Rating Scale
  • Beck Anxiety Inventory (BAI)
  • Generalized Anxiety Disorder-7 (GAD-7)
  • Trauma and PTSD Symptom Scale

What to Include in a Treatment Plan for Trauma + Example

After you have completed the appropriate assessments, you can review the information you have gathered to develop a treatment recommendation and develop your treatment plan. For this article, we will be walking through the development of a trauma treatment plan example while following the format of the treatment plans available at TherapyByPro.

Example for John:

John is a 34-year-old male who sought treatment for what he identified as depression. John reported being single and explained that he is a combat Veteran who ended his contracted period of service as expected, approximately 9 months ago. He explained that he did have a hard time adjusting to civilian life, and reported struggling with a depressed mood, decreased interest in pleasurable activities, sleep disturbances, and low energy. John was able to get a job as a mechanic at a friend’s garage and noted that his symptoms have impacted his work negatively along with his relationships. John shares that he has experienced frequent thoughts of death, and denied having a plan and intent. John denied the use of drugs and alcohol and denied having mental health concerns in the past. John denied experiencing symptoms related to PTSD including nightmares, flashbacks, hypervigilance, and intrusive thoughts of a trauma. He reported being in good physical health and denied having any health concerns. He did note that he has lost his appetite as of late and that he is not enjoying his favorite foods as he did before.

John shared that he was self-referred to treatment and explained that he has had a few comments from family and friends who shared that they were concerned about him, which made him feel as though his current challenges were obvious to others. He denied being on medications and working with other mental health professionals.  

Agencies Involved and Plans for Care Coordination

Agencies that you may need to coordinate care with include other mental health professionals, primary care physicians, and prescribing physicians or psychiatrists. With the proper consent, you can speak with other professionals about your treatment with John and how it relates to the care they are receiving with the other professionals. In this case, John was self-referred and is not working with relevant treatment providers. Should this change down the road, you can sign the appropriate consent, and adjust your treatment plan accordingly.

Example for John:

Other Agency: None at this time

Plan to Coordinate: N/A

Clinical Diagnoses

John’s current symptoms indicate that he is experiencing a major depressive episode. Though he does not appear to be at risk of harming himself or others, his symptoms do warrant mental health treatment. Some of the symptoms that he is experiencing that support this diagnosis include:

  • Depressed mood most of the day, nearly every day.
  • Markedly diminished interest or pleasure in activities.
  • Significant weight loss and decreased appetite.
  • Insomnia.
  • Fatigue or loss of energy.
  • Feelings of worthlessness and excessive guilt.
  • Diminished ability to think or concentrate.
  • Recurrent thoughts of death

Example for John:

Clinical Diagnosis:

  • Major Depressive Disorder, Single Episode, Severe Without Psychotic Features, F32.2
  • Supportive Assessments: Beck Depression Inventory: 55
  • Clinician-Administered PTSD Scale (CAPS), score 19      

Current Medications and Responses

In this case, there is no indication that John is currently taking medications. He denied a history of mental health concerns and denied having any medical health concerns. During your assessment, it may be appropriate to refer him to a psychiatrist who can assess the need for medications to manage his current symptoms, including his low mood, fatigue, low energy, and disinterest in pleasurable activities.

Examples for John:

Medications: None at this time

Presenting Problem and Related Symptoms

The presenting problem section of your treatment plan should give the reader a full understanding of John’s presenting concern, symptoms, level of impairment, and related history. This section can be helpful for other members of a multidisciplinary team so that they understand his case and can provide the appropriate interventions and strategies.

Example for John:

John, a 34-year-old male combat veteran, presents with Major Depressive Disorder following traumatic experiences during his last military deployment and difficulty adjusting to civilian life. His symptoms include persistent sadness, anhedonia, insomnia with trauma-related nightmares, fatigue, reduced appetite and weight loss, cognitive impairment, feelings of worthlessness and excessive guilt, and recurrent thoughts of death. These symptoms have significantly impaired his occupational performance, social interactions, personal care, and physical health. John’s clinical presentation necessitates a comprehensive treatment approach involving trauma-focused therapy, assessment for medication management services, and regular monitoring to address his depression and improve his overall functioning.

Goals and Objectives

Let’s talk about your trauma goals and objectives that are included in your treatment plan. We will want them to be specific to John’s individual needs, including his symptoms, coping abilities, available support, and other resources. We encourage you to consider your client’s readiness for change and ensure that the goals you create are realistic and within their capabilities.  Your treatment plan goals can be described as long-term goals, typically broken down into objectives or short-term goals. Continue reading for John’s goals and objectives: 

Goal 1: Address Trauma-Related Symptoms

Objective 1: Engage in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) sessions to process traumatic memories and develop coping strategies.

Objective 2: Practice grounding techniques to manage distressing symptoms of hyperarousal and dissociation.

Objective 3: Build a safety plan to manage triggers 

Goal 2: Improve Interpersonal Relationships and Social Support

Objective 1: Practice effective communication skills to express needs and boundaries in relationships.

Objective 2: Expand his social support network by reconnecting with supportive family and friends.

Objective 3: Participate in group therapy sessions focused on building social skills and fostering peer support. 

Goal 3: Enhance Coping Skills and Emotional Regulation

Objective 1: Develop a personalized toolbox of coping skills to manage distressing emotions and intrusive thoughts.

Objective 2: Address maladaptive coping mechanisms, such as substance use or self-harm, through harm reduction strategies and alternative coping strategies.

Objective 3: Enhance emotional awareness and expression through expressive arts therapy or journaling exercises.

Specific Interventions to Be Used

Interventions have been carefully selected that align, and support, John’s treatment plan, to help him achieve his goals. Utilizing evidence-based interventions and trauma-informed approaches is essential for John’s recovery journey and can address his specific needs and challenges, aiming to have a significant impact on his well-being. Referencing this section of the treatment plan before sessions can serve as a valuable guide, reminding you of the interventions best suited to support John’s progress and healing process.

Examples for John:

Intervention/Action: Cognitive restructuring to challenge and modify maladaptive beliefs tied to the trauma experienced while in the military

Responsible Person: Counselor A and John

Intervention/Action: Utilizing new coping skills, including deep breathing and muscle relaxation, to cope with psychological distress

Responsible Person: John

Intervention/Action: Utilizing mindfulness practices, such as meditations and grounding exercises, to reduce distraction throughout his day and to help cope with psychological distress

Responsible Person: John

Intervention/Action: Using expressive arts as a way to facilitate self-reflection, and express thoughts and emotions with the use of a healthy outlet. This could include journaling, drawing, painting, sculpting, etc.

Responsible Person: Counselor A and John

Family Involvement

For some, family members can be a vital source of support and encouragement. In John’s case, there is no indication that his family would be included in his therapy. However, this can always change, and you would later adjust his treatment plan.

Example for John:

Family Involvement: None at this time

Additional Services and Interventions

The additional services and interventions would include additional treatment options and holistic approaches that could enhance John’s treatment outcomes. At this time, John would likely benefit from participating in a support group for Veterans which could provide him with an additional source of support and validation.

Example for John:

Additional Services:  Weekly Support Group for Veterans

Estimation for Completion

The length of time needed for therapy is dependent on several factors, including the severity of his symptoms, his progress in treatment including the specific goals and objectives outlined in his treatment plan, and his response to interventions. Generally, outpatient treatment for trauma-related issues such as PTSD and depression can range from several months to a year or more, depending on individual needs and circumstances. At this time, we will estimate that his treatment will be complete in 6 months due to the need to address trauma-related symptoms, improve interpersonal relationships and social support, and enhance coping skills and emotional regulation.

Example for John:

Duration of 6 months of weekly individual sessions, with continued participation in a Veterans support group. The date is to be adjusted as needed. 

Aftercare Plans

Thinking about aftercare plans from the start is important because sometimes clients might not finish their treatment program for different reasons. It could be that the treatment doesn’t feel like the right fit, or they require a different level of care. Whatever the reason, aftercare plans and referrals must be ready as if you were finishing treatment today.

Example for John:

Aftercare Plans include:

  • Continue engaging in mental health treatment and counseling
  • Participate in a support group for Veterans
  • Meet with primary health physician to discuss current symptoms

Final Thoughts On Creating a Treatment Plan for Trauma

Creating a treatment plan for trauma is a deeply personal endeavor that demands empathy, understanding, and flexibility. It’s about recognizing your client’s unique journey and meeting them where they are in their healing process. By valuing your client’s experiences and strengths, you can collaboratively develop a plan that honors their resilience and empowers them to reclaim their sense of agency and well-being.

If you are looking for additional resources that can enhance your clinical work, we encourage you to review the mental health-related worksheets that can be incorporated into individual and group settings. Worksheets that may be impactful when working with clients who have experienced trauma include:

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 forms, worksheet, and assessments here.

Resources:

  •  “What Is Trauma? – Trauma-Informed Care Implementation Resource Center.” Trauma-Informed Care Implementation Resource Center, July 8, 2022. https://www.traumainformedcare.chcs.org/what-is-trauma/.
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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