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Example: how to build a mental health treatment plan (Draft)

Updated: May 3, 2023


****CONTENT WARNING****

My trauma history especially childhood trauma, symptoms I experience, and my feelings towards my abusers may trigger readers.


My Schizotypal Disorder w/DID

By Alantis Perkins


In this example learn how how to develop an Individual Treatment Plan (ITP) or Individual Action Plan (IAP) Draft for Mental Health




*Interpersonal Relationships, Preferences, and self-perception 

- social anxiety; I get really bad social anxiety around folks I can't trust and some anxiety around those I should trust making it hard to socialize effectively and maintain relationships. I even prefer going to the gym at night when there is few to no people around so it's less stimulating and I don't have to worry about traumatizing situations occurring 

- self-perception; broken or damaged, evil, useless, unworthy, lost, and hated/disliked, demon

- preferences and desires; I prefer to keep my social circle small of few people because it's less likely I'd come across Trauma true evil nature of humans I'm a survivor of and If I can I'd try to isolate myself for awhile for comfort and to recharge, where I don't have to worry about fears, concerns, worries, over stimulation, etc.

- my persistent or excessive social anxiety doesn't get better with familiarity

- I joke alot, especially to show affection




*Thought Disorder and Cognitive disorder

- I have trouble recognizing my emotions and other people's 

- sensory processing issues, difficulties and experiences 

- strong internal fantasies and illusions

- Pragmatic Difficulties

- "splitting" black or white thinking of all safe or all not safe



*language and conversational discrepancies 

- too open and honest and transparent with strangers and people I know 

- sometimes too vague or overly detailed 




*unconventional Beliefs and odd, magical thinking 

- I always feel like reality isn't real, that my reality is created by the creators, producers, artists, etc.

- I always feel like there's an audience that expects me to preform for them




*unusual perceptional experiences and distortions

- alot of times I can see, hear, feel, and or sense my parents, loved ones, alters, etc.

- some people I know seem like alters of mine but on the outside of head and it's sometimes hard telling the difference 

- species dysphoria (werewolf/human hybrid), lycanthropy (werewolf/human hybrid)

- hearing and vision sensitivity

- hyperreactive or impaired reactions to sensory input

- joint pain, headaches, dizziness, chest pains and stomach aches, etc. (fibromyalgia)

- body dysmorphic/Body dissatisfaction



*unusual appearance 

- history of styling my hair like an Dragon Ball character (Gohan)

- history of wearing pajamas, especially footie pajamas to stores and to other people's houses

- in middle school I would wear my Spider-Man costume underneath my clothes even in 90 degree weather in case someone needed my help 



*paranoid ideation, ideas of reference (not delusions of reference), and transient psychotic symptoms

- I always feel like someone or something wants to snatch my safety away from me

- I always feel like someone or something wants to turn me evil, into the bad guy

- I can sense people ploting against me to take my safety away and turn me evil, into the bad guy

- sometimes when I'm stressed people look different and odd

- I turn off my webcam so you can't see me because both my eye contact issues and I have a weird feeling the person I'm talking too could steal my safety 




*Dissociation

- Dissociative Identity Disorder (12 alters)

- Dissociative amnesia 

- Dissociative Fugue

- flashbacks

- Derealazation and Depersonalzation

- Identity disturbances

- deja vu episodes

- Jamais vu episodes 

- age sliding 

- schneiderian first-rank symptoms

- dissociative schema modes and Dissociative psychotic episodes/features please refer to Dissociative Neurological Symptom Disorder and including cognitive disturbances





*behavior and impulstivity

- self-destructive and reckless at times

- trouble with eye contact

- stimming eg. Howling like a wolf/werewolf, uncontrollable laughter, singing Michael Jackson's hehe's and shamoan's, singing specific tunes, hand flapping and snaps, hitting myself, etc.

- I joke alot; I have alot of dark humor and interests I even enjoy watching things like cyst popping videos or watching porn to laugh or other reasons other than sexual

- adjustment difficulties




*Obsessive Interests

- wolves and werewolves

- the Addams family and the Munsters (wish my family were more like the Addams and Munsters families)

- paranormal

- horror and suspense films

- as a child I was obsessed with Michael Myers 



*affect and emotional regulation

- hypomania episodes; I might think or feel I'm a werewolf demon or Batman for example, especially in psychotic states of hypomania. You might catch me researching and studying all types of Batman skills to become Batman/crime fighter. Symptoms include but are not limited to; rapidly researching, flights and or racing of emotions, exercising way more, high self-perception, socializing more, decreased need for sleep and increased sleep disturbances, feeling physically and mentally strong and powerful with werewolf demon abilities or Batman abilities, overly focused on goals, etc.

- inappropriate and or incongruity of affect and feelings about people, places, things, and experiences

- positive and negative Schizotypal symptoms; positive schizotypy is characterized by odd beliefs, unusual perceptual experiences, negative affect, and affective dysregulation, whereas negative schizotypy involves avolition, asociality, diminished positive affect

- depression and anxiety 

- impaired empathy and sympathy 



*Sleep Disturbances

- nightmares

- sleep terrors and sleepwalking 

- insomnia, hypersomnia, etc.

- sleep-wake syndrome 



*Developmental disturbances or delay

- Mixed Developmental Disorder of scholastic skills

- Mixed Specific Developmental Disorder 

- lack of or impairment in social awareness



*affected areas; social, abusers, volunteering, family, community, etc.; 

- relationships; I have very few friends but I struggle to trust them and always put them through trust tests that ends up putting stress on the friendship

- I always feel weird about my abusers, sometimes I love them, sometimes I hate them, some I just hate while others I just love, I know it's hard to understand I don't understand it myself. I teeter on edge of sanity and insanity with it. I even have a protocol that's meant to take them and myself out if things get too much to handle and they keep abusing others. There's another protocol that's meant to have them all arrested and locked up for life. It depends on how strong I am at my breaking point.

- work/volunteer, school, etc.; I've had trouble working with others due to me not trusting them and would put them though elaborate trust tests that most of the time they didn't know it and it all got me no where good

- I'm elusive with extended family because they indirectly remind me how I don't fit in and don't belong

- I'm elusive with the community because I'm worried about safety and coming across people who want me to be a bad guy




*History

- reality testing; my reality testing is always pretty good. However, when I'm stressed I might get a C or D grade


- trauma history as a whole from my childhood into my adulthood 

● domestic abuse; multiple ex-girlfriends of my past were abusive for example one ex didn't want me to leave her over her abusiveness so she staged a scene for police and paramedics. She claims I hurt her the police believed her on the spot and even hurt me. When the paramedics came to assess her they could tell her injuries were self-inflicted. I had gotten no apologies from the officers. Another time one ex-girlfriend groomed me into underage stripping. 

● physical abuse; a brother in-law was abusive all though my childhood and adolescence even forced me to witness his abuse of my sister repeatedly. When I was a child into my early teens my dad went overboard in his ideas of "disciplining" me.

● financial abuse; this one I have to verbally explain 

● sexual abuse in my childhood and early teens; when i was 9y to 10y my 16 year old babysitter would have intercourse with me introducing me to sex and related activities but I still struggle to consider my experiences sexual abuse

● community violence; getting into a fight with a gang over them stealing my middle school candy. Then in a separate incident a small Police force unit of 5 officers threatened to shoot me and my service dog. Daily episodes of community racism and bigotry on me.

● survivor of black sheep/golden child and scapegoat trauma 

● other traumas; me being an orphan loosing my parents to cancers, witnessing violence since childhood, my siblings traumatic lives, the many deaths of loved ones since childhood, childhood foster care/psudo foster care experiences, brother almost had gang members kill me and our mother in my childhood, cluster b abuse, trauma by a few providers, and in my childhood I was in a car accident


My trauma narrative 




My parents obituaries 

My mother, Gloria Perkins;



My father, Calvin Johnson;




- OCD symptoms; if I do good then I can wash and scrub away trauma and sin of mine and other folks, if I keep hope (which feels like false hope at times) then the fabric of my inner universe stays safe, doing what I can to keep me and loved ones safe, justice and vengeance 


- Developmental history; delayed scholastic skills, delayed written and language skills, athletic skills delayed due to delay in motor movements, however I had an advanced vocabulary as a child even though I didn't seek out conversations, I also liked puzzles especially rebuilding/repairing electronics as a child 


- Loss of systems of meanings; there were alot that used to give me hope and happiness but the systems of and my examples of hope and happiness has been dismantled long ago but I still keep the spark of hope and happiness alive out of OCD obsession


- self-harm history; I used to cut and do dangerous things eg. walking into traffic, head banging, not disclosing ailments to providers, writing and drawing on myself, self-abuse by proxy 

by pissing off my abusers deliberately for them to abuse me more


- history of suicidality or homicidality; I've attempted suicide a dozen times in my teens, my protocol against my abusers is a plan I've never attempted and thoughts and feelings about initiating my plan are inconsistent because I usually wrestle with the thoughts and feelings controlling them despite the overwhelming CPTSD symptoms my abusers caused and currently aggravate my symptoms. 



*Personality traits

- sociopathy/psychopathy

- obsessive-compulsive Personality traits; all traits including the trait of a strong and rigid adherence to moral and ethical codes, but didn't truly meet the disorder because the traits didn't inhibit me from achieving goals and aspirations

- TLE Personality/Geschwind syndrome traits; most symptoms including hyperreligiosity

- autistic traits eg. Pragmatic difficulties



*Medical Comorbidity

- Temporal Lobe Epilepsy

- complex PTSD 

- Fibromyalgia 

- Lupus SLE 

- Mixed Specific Learning Disorder of scholastic skills


Previous/past diagnosis 

- borderline personality disorder 

- psychotic disorder, unspecified 

- major depressive disorder with psychotic features 

- Bipolar disorder unspecified 

- Autism Spectrum Disorder (r/o)

- ADHD 

- OCD

- Obsessive-compulsive Personality Disorder 

- Geschwind Personality Disorder (TLE)




Other current or past difficulties 

- 'failure to launch' syndrome

- complicated grief bereavement or Prolonged grief disorder

- Polyphobia (eg. Relationships & commitment, crowds, loss of personal safety, loss of personal control, loss of personal identity and important memories (D.I.D), etc.)

- Survivor's guilt 



Notes:

In my records you will see things noted by providers that are not accurate due to lack of context and details.


1. As a child in middle school I did write alot of short stories and poems about how I was feeling and things that has happened to me and taken from me. So, none of my works were or are about me raping anyone, as was said by a provider. Again, my works are a reflection of how I was wronged, hurt, and robbed by my abusers and tormentors, and how I feel about it. 


2. Another thing that had been written by a provider was that I was jailed for fighting another student and hitting a cop in middle school. I was not jailed nor was the school police officer hit by me. My mother had just passed away from cancer and the student I fought with knew this but he proceeded to talk bad about my deceased mother. So we went into an all out brawl over it. The officer was called in to breakup the fight, he asked me to stop and not to hit the student in font of him. I refused. I continued to fight the other student in a vengeful rage. And yes, all the bad things my abusers and tormentors have done to me I took out on the student also. Which wasn't fair to him. The officer arrested me on the spot and drove me to the station where I was not put behind bars. I sat at the front desk waiting for my father, Calvin Johnson, to pick me up.




Reason for treatment: I want better lasting relationships


Assessed needs: Autism, schizotypal personality disorder, Dissociative Identity Disorder, CPTSD


Risk self assessment;

Danger to self: no

Danger to others: no

Danger to property: no


Notes: I'm safe with myself and others but it doesn't seem that way in context of talking about and thinking about my abusers. I need to use my stress ball more to limit confusion and to have an alternative to crying fits, etc.




Treatment goals

I am seeking therapy to establish and improve personal and community relationships. My Schizotypal w/DID symptoms makes that difficult. 



Objective: alters and I don't want to integrate. We want to establish functional multiplicty, safety, and work through trauma so we can destroy the barriers that prevent lasting successful relationships. 


- Goals: deconstruct relationship barriers and construct helpful relationship skills

- intervention: help us not integrate but learn to work together and co-habitation toward life and life goals, building personal sense of safety by brainstorming ideas and executing them, use ACT with trauma focus to treat my trauma and grief history, utilize Bentley my service dog in treatment. ACT, social and relationship skills training, medication, social therapy, group therapy, peer support

- Service Modalities: 1x1, telehealth, home therapy

- supports and resources: Cindy my POA & Healthcare Proxy and Bentley my service dog and my website LibertyMoon.org 

- measures of success: Deconstruct 2 relationship barriers and construct 2 helpful relationship skills 1 x month

- potential barriers: symptoms of Schizotypal w/DID, little to no therapeutic alliance, going on irrelevant tangents, lack of reliable transportation for myself and Cindy and Bentley




Objective: We want to work through social anxiety in the moment and other social issues and symptoms to effectively socialize, build and maintain trusting and lasting relationships. 



- goals: objective: work through social anxiety and other symptoms

- intervention: utilize Bentley my service dog in treatment, learn coping skills that effectively mitigate social anxiety and other symptoms that interfere with positive relationships. ACT, social and relationship skills training, medication, social therapy, group therapy, peer support

- Service Modalities: 1x1, telehealth, home therapy

- supports and resources: Cindy my POA & Healthcare Proxy and Bentley my service dog and my website LibertyMoon.org 

- measures of success: use 2 social and relationship skills in social situations weekly 

- potential barriers: symptoms of Schizotypal w/DID, little to no therapeutic alliance, going on irrelevant tangents, lack of reliable transportation for myself and Cindy and Bentley




Objective: I want to improve communication and manage pragmatic difficulties to cultivate positive relationships 


- Goals: objective: build or improve positive relationships 

- intervention: utilize Bentley my service dog in treatment, learn effective communication skills that promotes and fosters positive stable relationships, learn to recognize pragmatic difficulties and effectively resolve them, teach my supports to recognize my pragmatic difficulties so they can assist with support eg. assisted communication. ACT, social and relationship skills training, medication, social therapy, group therapy, peer support

- Service Modalities: 1x1, telehealth, home therapy

- supports and resources: Cindy my POA & Healthcare Proxy and Bentley my service dog and my website LibertyMoon.org 

- measures of success: build or improve 1 relationship a month/every other month

- potential barriers: symptoms of Schizotypal w/DID, little to no therapeutic alliance, going on irrelevant tangents, lack of reliable transportation for myself and Cindy and Bentley




Objective: I want to work through relationship stressors to maintain positive relationships 


- goals: objective: maintain positive relationships 

- intervention: utilize Bentley my service dog in treatment, have casual conversations about Interpersonal stressors and identify issues to resolve and brainstorm solutions. ACT, social and relationship skills training, medication, social therapy, group therapy, peer support

- Service Modalities: 1x1, telehealth, home therapy

- supports and resources: Cindy my POA & Healthcare Proxy and Bentley my service dog and my website LibertyMoon.org 

- measures of success: work through 2 relationship stressors a week/every other week 

- potential barriers: symptoms of Schizotypal w/DID, little to no therapeutic alliance, going on irrelevant tangents, lack of reliable transportation for myself and Cindy and Bentley



Potential Team:

1. Caseworker 

2. Social Worker 

3. Therapist 

4. Psychiatrist

5. Community Worker

6. Peer Specialist/therapeutic mentor

7. Peer-friends 




Useful information about;


Schizotypal Personality Disorder 







Dissociative Identity Disorder 




Complex PTSD 




Prolonged Grief Disorder




Polyphobia 





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