Mrs. Boland is a 76-year-old female presenting with significant symptoms indicative of depression and anxiety. She reports experiencing a decrease in appetite, persistent pain, fatigue, and a profound sense of longing for home. Mrs. Boland articulated her feelings by stating, “I am working hard in here because I am so ready to go home.”
Upon arrival, Mrs. Boland greeted the clinician with warmth and cheerfulness. She was observed resting in bed but was appropriately dressed and well-groomed. During the session, she demonstrated orientation to person, place, and time, indicating sufficient cognitive capacity to benefit from psychotherapy. Her mood was notably calm, with an affect that was congruent with her verbal expressions. Mrs. Boland actively engaged in the conversation with the clinician, demonstrating both understanding and willingness to participate in her treatment plan.
During the session, the clinician emphasized the significance of sustaining a positive outlook and fostering hope. The clinician also addressed the necessity of adhering to a structured process to ensure a safe transition when returning home. Mrs. Boland expressed comprehension of these concepts and agreed to apply relaxation techniques as a strategy to manage her anxiety and depressive symptoms.
The clinician has outlined specific treatment goals to support Mrs. Boland in her recovery journey:
Mrs. Boland will work toward reducing her daily anxiety levels by implementing positive coping mechanisms. This goal includes managing her anxiety when it exceeds a severity level of 5 for the next 90 days. Progress will be evaluated through a combination of self-reports from the client and observations made by the therapist. Currently, there is no noted progress regarding this goal.
Mrs. Boland aims to partake in at least one enjoyable activity on five out of seven days each week for the upcoming six months. Similar to Goal 1, progress will be assessed through self-reports and therapist observations. To date, Mrs. Boland has not demonstrated progress towards this goal either.
The clinician recommends that Mrs. Boland continue with weekly individual therapy sessions over the next 3 to 6 months. These ongoing sessions will be crucial in assisting her to effectively manage her symptoms of depression and anxiety. A re-evaluation of her treatment plan will be conducted in 90 days to assess progress and make necessary adjustments. Presently, the prognosis for Mrs. Boland is considered fair, indicating that with continued therapeutic support, improvement is possible.