MHC Comprehensive Case Conceptualization Template
Student Intern: Ryan McDonald
Theoretical Orientation and Integrated Personal Approach
I.
My primary theoretical orientation is Cognitive Behavioral Therapy (CBT) – more specifically,
Rational Emotive Behavioral Therapy (REBT), based on the work of Albert Ellis which laid the
foundation of modern-day CBT. This primary orientation is paired with an Adlerian approach to
lifespan development. This approach promotes and creates an encouraging environment for the
client, as well as empowers them to explore not only the sources of their current maladaptive
thoughts and decisions, but also instructs how to continue this thought challenging pattern moving
forward, into goal setting and a healthier, more balanced lifestyle (Chan, p.110). The combination
of Adler’s belief that emotions and behaviors are based on subjective interpretation of experiences
and may fuel “faulty logic” (Carlson, Watts & Maniacci, p.12) lays a strong foundational approach
to the main tenets of REBT, in which Ellis describes this “faulty logic” as either rational or irrational
beliefs, based on a number of different combined influences, and which directly influence a
person’s positive or negative feelings, goals and outlooks (Ellis, 1973). From this approach, the
“faulty logic” becomes the “irrational beliefs” of REBT, challenging clients to consider their own
thought patterns and acknowledge their ability to shift the irrational to rational, creating a
present-day object of change based on thought and belief patterns from the past.
This approach creates the opportunity for perspective changes and declarative statements to be
made in session and has the ability to empower clients to continue this process independently
after learning how to self-assess and challenge rationality. By examining the client’s presenting
concerns, behaviors and emotions, the process seeks to identify the underlying core beliefs and
thought patterns that are driving those characteristics. Those thought patterns and core beliefs
are established by the values and principles of the individual. Once those thought patterns are
identified, the search can begin for how those thought patterns or beliefs were learned or
acquired, leading into challenging the rationality or validity of the thoughts and beliefs. By
targeting the underlying core value and belief system to determine rationality or agreement based
on the client’s desired level of change, a decision by the client can be made as to what alternative
thought pattern or value would be acceptable and/or agreeable, thereby directly affecting their
emotional responses and behaviors when presented with situations that utilize that process.
While I firmly believe in the goal setting process and ongoing development, this opportunity for
direct effect and client action is appealing and aligns well with my personal characteristics. From
personal strengths in analytical thinking, reframing in communication, objective thinking and
process analysis, this type of approach pairs well with my strengths and functions strongly
alongside the empathy and positive regard within session.
II.
REBT promotes a positive, encouraging and supportive partnership with the client, focusing on
establishing an optimistic environment in which the client is capable of learning and change.
However, it is also an environment that is used to be “risk-taking, intelligent and knowledgeable,
vigorous in detecting and disputing irrational ideas” (Chan, p.123). This requires fully involving the
client in the change process, establishing them as both participants in identification and students
in learning how to effectively challenge those thought patterns moving forward. Interventions
would focus on patterns of lifestyle and assessment, potential work on any underlying
developmental experiences or beliefs driving behavior and utilizing cognitive techniques and
disputes to challenge current irrational beliefs or behaviors.
Carlson, J., Watts, R., & Maniacci, M. (2006). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association.
Chan, F., Bervan, N., & Thomas, K. (2015). Counseling theories and techniques for rehabilitation and mental health professionals. New York,
NY: Springer.
Ellis, A. (1973). Humanistic Psychotherapy: The rational-emotive approach. New York, NY: Julien.
(NOTE: The first citation referencing Chan p.110 is a generalized citation supporting the REBT description and information. The specific
sentence is taken from a personal final paper in earlier coursework, describing the combination approach of REBT and Adlerian.)
Counselor Identity
My name is Ryan, and I’m an internship student here at New Life, under the supervision of Dr. Gilbert. I’m
currently in the final stages of my degree with Southern New Hampshire University. Prior to my work here, I
was on staff and Adult and Teen Challenge of the Midlands located in Colfax, also in a counselor/mentor role.
As we get started, I’d like to share with you some things to expect and to quickly go over my personal approach
to counseling. I primarily practice from what’s called Rational Emotive Behavioral Therapy, or REBT. This
approach allows us to process through your thoughts, feelings and emotions and look at things from a different
perspective – challenge things that may not be true or may not line up with your goals and values, reinforce the
things that are true and you feel strongly about, and so on. By processing through your thought process and
your emotions, the benefits can help you to plan for the future in ways that truly line up with your beliefs and
values. It can also teach how to continue this process on an ongoing basis, helping you to run new information
through this same filter going forward.
As we talk through the different topics and areas you’d like to discuss, you may notice that from time to time I
may stop you to ask for more details or reasons for feelings or choices. Part of that is because I’d like to learn as
much as you allow me about you to best understand how I can be a resource for you. It is also because one of
my focuses is to help understand why you’re feeling a certain way or making choices/decisions a certain way,
and determine how those line up with your goals, what you are here to address and work on, and how we can
best move forward with treatment and with the future. At times this may feel like a lot of questions or
challenging certain items – really, this is my way of learning about you as best as possible, so I can offer the
most effective support and assistance as possible.
Client Information
Initials: M.C.
Developmental Stage/Age range: 24
Cultural Identity: Male Caucasian
Length of time in treatment: 4 sessions, over
a 6-week time span
Background Information
Mental Status Exam:
At each session, client has presented as well-groomed and with a calm demeanor, oriented to time, place and
situation. Client is able to display limited affect, normal range of tone of voice and speech. During our first
session, client did have instances of strong emotions when discussing past experiences of suicidal
ideation/attempts and abuse – crying, shaking voice. While calm in discussion and demeanor, client did share
depressive thoughts and feelings during our first session – worthlessness, guilt, shame - including suicidal
ideation at that time. In the sessions following, these patterns have improved with no instances of suicidal
ideation, and client has expressed more hopeful thoughts and positive feelings as his symptoms have begun to
show improvement and his support structure has started to rebuild relationships with him.
Sexual History
Activity: No discussion of client’s most recent sexual activity, if any. Client has disclosed that he was sexually
abused from the age of 10-11 but has not yet disclosed the nature of the abuse or the majority of identifying
details about his abuser.
Partners: Client has not yet discussed/disclosed any identifying details describing his childhood abuser, other
than it was an older male. Future discussion and assessment will be needed to determine client’s comfort level
with sharing any additional information.
Practices: Future assessment is needed
Protection from STDs: Not applicable; future assessment may be needed
Past history of STDs: Not applicable; future assessment may be needed
Prevention of pregnancy: Not applicable
Risk Assessment
Suicide: Client has disclosed multiple past incidences of suicidal ideation and plans, with one attempt.
Attempt one occurred 3 months ago as the result of depressive symptoms/feelings and a substance abuse
episode (alcohol) and involved wrist cutting on his left wrist, requiring multiple stitches. This event occurred in
front of client’s parents, who administered care and transported him to the hospital, where he was treated
through short-term inpatient care. Client states that he still experiences limited flashback episodes and has
described certain events which triggered acute anxiety and emotional response.
Event two occurred shortly after attempt one and involved client walking alongside a highway with a family
member on the phone, threatening to jump in front of a truck. This episode also involved substance use/abuse
and extreme depressive symptoms. Client eventually was discovered by police and transported to a local
hospital, where he was treated through short-term inpatient care.
Client stated during our first session that he did at that time still experience times of suicidal ideation, but
without a plan or attempt. Client is currently in a long-term inpatient facility with protection in place and
limited access to means. We did establish a safety plan at that time in addition to the residential facilities’
precautions. In successive meetings, client has stated no further suicidal ideation and successful
implementation of the safety plan.
Homicide: Client stated he had no desire, thoughts or intentions of hurting others.
Abuse: Client disclosed during our first meeting that he experienced sexual abuse at the hands of an ”older
male” during the ages of 10-11. Through the course of our four meetings, we have focused on the more urgent
symptoms of depression with suicidal ideation and acute anxiety, with the knowledge that there is potential for
the abuse experience to be an underlying contributing factor to a number of his current maladaptive patterns.
Further assessment is planned to explore this issue, at the comfort and willingness of the client.
Other Risk: Client has a past and recent history of Substance Use/Abuse Disorder, primarily involving alcohol
and marijuana use on a daily basis. Client has recently received both a 2 nd and 3rd OWI violation(s) over the
course of a 2-day period, leading to his seeking treatment. At this time client is currently participating in a
protected inpatient treatment program and is expected to be court ordered to complete. If client does leave for
any reason, substance use, or substance use combined with other activities, should be considered extremely
high risk.
Comprehensive Overview of Presenting Concern
Presenting Concern:
Client is a 24-year-old Caucasian male who is currently in an inpatient treatment facility for uncontrollable
substance use/abuse and depression, both of which have been previously diagnosed. Client describes his
pattern of substance use beginning at age 14 with use of tobacco and alcohol. This continued as what he
described as “casual” use until after high school, when occasional use increased to every day, and eventually to
physical dependence with binge episodes, lasting anywhere from a few days to over a week. Client could not
hold a job and moved back in with his parents. Client notes that the increased use corresponds to his increase
in feelings of guilt and worthlessness every day. He began to withdraw from friends and activities in order to
use. First suicide attempt was at his parents’ home, cutting his wrist in front of them. Client was committed by
his parents to a 30-day treatment program in Florida. Following treatment, client’s use pattern continued, and
he received both 2nd and 3rd OWI charges within a 2-day span. At this time, he was kicked out of his parents’
home and went to live with another family, who were members of their church. His second suicidal event was
shortly thereafter, threatening to jump in front of a truck from the side of a highway. Following this episode
client was hospitalized and sought help in long-term treatment. Client also shared during initial session that he
experienced sexual abuse at the hands of an “older male” from the ages of 10 to 11. He shared this was a
congregant at the church where his parents are pastors and in which he grew up. He also shared that this was
the first time he had ever shared this episode with anyone. Client states that growing up he always felt
watched, experienced feelings of unrealistic expectations, and eventually felt separation from his family due to
his behavior patterns and use. States feeling of guilt for past drug experiences with his younger brother,
introducing him to a drug lifestyle in which he is still in. He expressed feelings of guilt, shame, powerlessness
and worthlessness as a result of his childhood abuse. Client also stated recent experiences of anxiety and
physical response due to triggered memories of his first suicide attempt. He gave a recent example of being in
the kitchen of his current facility and seeing someone cutting up chicken. He began shaking and sweating,
feeling fear and anxiety, finally removing himself from the situation in order to calm down. Client currently
wears a wristband over his left wrist in order to cover the scar from the incident. He expresses a clear desire to
address his depressed mood and substance use – wanting to “feel better and live a different life.” He also
desires to eventually address his previous abuse experience in more detail when ready.
Current Triggers:
During the initial meeting, client expressed a number of different triggers that were very active, most of which
were circumstantial in nature. He stated that he has a tendency to get “in his head,” which causes him to
contemplate the gravity and nature of his current situation which has a tendency to increase his depressive
thoughts and, at that time, his suicidal ideation. Since that time, as he has made progress through the program
and with some distance from recent episodes, he states that these depressive thoughts have slightly decreased,
and the suicidal ideation no longer occurs. Client has also stated at the beginning of treatment, any contact
with his parents were current triggers not only for memories of the suicidal event, but also of the pain and
damage his decisions and actions have caused, which also increase feelings of stress, anxiety and worthlessness.
Over the course of the past few weeks, client has begun to rebuild regular contact with his parents and family,
which has provided some hope and support. Client mentioned a specific incident in the kitchen which triggered
direct memories of his first suicide attempt, causing anxiety and stress along with physical responses – sweating
and shaking. He had to remove himself from the situation to calm down. He said “other things remind me
sometimes” but was not specific and stated they were not to that level with regard to symptoms. Client states
that interactions with other individuals within his current facility have the ability to trigger feelings of anger, and
eventually feelings of worthlessness and shame. Client states that he could not identify any triggers with regard
to his childhood sexual abuse, although in later sessions, he did reveal that he has been thinking about the
episode more and more since we discussed it, which has increased feelings of guilt and shame. Of note, these
are all current triggers within his current controlled environment.
Prior to treatment, client has stated that his primary trigger was his relationship with his parents, reminding him
of childhood feelings of expectation, their expectations of him as an adult which he never felt he could live up
to, and his perceived feelings of them not supporting him through his substance use struggles. Client has made
statements in session that he feels as though “he is his biggest trigger,” as he tends to dwell on situations in his
head which drive him further and further into dark thoughts, causing him either to act on them or use
substances in attempt to escape them, which only makes them worse.
Maladaptive Patterns:
Primary maladaptive pattern is substance use – primarily alcohol, with additional use of marijuana and
methamphetamine. Client uses this as primary coping skill for feelings of guilt, shame and worthlessness.
Unfortunately, substance use as a coping skill for depression creates a circular pattern for him, exacerbating the
feelings which has led to two episodes of attempted suicide, acting out on previously consistent suicidal
ideation. Client has a tendency to withdraw from relationships during times of extreme use or extreme
depression, leading eventually to extreme isolation. Client acknowledges that he has a hard time trusting
people, including his family – therefore he does not commonly share emotions and will “put on a face” to hide
how he’s really feeling inside. This contributes to client’s self-identified circular thinking, when he will “get in
his head” and get more and more worked up over his feelings, driving him to either action or use. Due to his
substance use, client cannot maintain a consistent schedule, is unable to stay gainfully employed, and is
currently facing a number of criminal charges. In our last session, client made the self-aware statement that he
feels most of these feelings and behaviors stem from his unresolved childhood incident of abuse. Further
assessment into that episode is needed to confirm, although this does appear to be the catalyst for his initial
feelings and behaviors in his teenage years and fueling the ongoing cycle to present day. Client has attempted a
previous 28-day substance use and depression treatment program, along with numerous hospital stays (detox
and inpatient mental health) and admits that he was unable, and at times unwilling, to follow any of the
aftercare or follow-up plans for support. Currently the client’s environment limits access to some of his past
patterns – substances, suicidal plans/attempts – and he has stated a noticeable decrease in the severity and
frequency of his symptoms.
Developmental Influences:
Client is the third of four children (older brother, older sister, younger brother), born to parents who are pastors
of a smaller Evangelical church on the east side of Des Moines. Client has made direct statements to memories
of the expectations for behavior and attitude that were placed upon him by the family based on their role and
place within the community, especially when in and around the church, which was most of the time. Client
states that he remembers always feeling as though he was being watched and on display, that he needed to be
an “example,” and that this created a lot of self-pressure and self-expectation, as a result of the expectation of
others. Client does not list any abusive patterns or troubles within the home or between siblings. Client has
stated that although he acknowledges that he created chaos and emotional damage to the relationship
between he and his parents, that they have remained supportive throughout the process – taking him back into
their home, supporting him through treatments, and always offering their home for dinner at any time when he
was not living there. At current session, he stated that this relationship has begun to be restored through
heartfelt conversations and emotional expression, which he had always held at bay, due to feelings of needing
to “put on a face.” These feelings of repression, coupled with high expectations from family members and
environment created a vacuum for the normal feelings of relationship and intimacy through childhood, which
were unable to be fulfilled. This in combination with the abuse event at age 10-11 drastically affected any level
of attachment and intimacy both inside and outside the family. As the client got older and more independent, it
is easy to identify these patterns of isolation, the lack of coping skills, the inability to express and handle
emotions, and the eventual development of unhealthy, maladaptive patterns and extreme behaviors as a result
of these foundational steps perpetuating themselves through his life.
These early developmental influences were catalyzed by the incident of sexual abuse at age 10-11, which the
client self-acknowledges became a turning point in his thoughts, feelings and behaviors. In addition to the more
Adlerian family structure approach, Erikson’s theory of psychosocial development (Erikson, 1950) provides
another approach into how the timeframe of this traumatic event created ripples both forward and backward in
the client’s lifespan. With the abuse occurring at ages 10-11, according to Erikson this occurred during the
Industry vs. Inferiority period of “School Age.” At a time when adolescents are learning to adapt into
relationship and begin to lay the foundation of the creation and cementing of an independent identity, the
traumatic event created and cemented direct and unwarranted feelings of inferiority, which he was ill-equipped
to process at that time, and has yet to fully process through to the current day. This event occurring at this key
developmental time directly affected the client from an attachment standpoint, fracturing his ability to be
intimate with anyone, including his own family.
In addition, this occurred on the border of the next developmental phase – Identity vs. Role Confusion, or
Adolescence – during which time, Erikson explains that adolescents develop a “new sense of ‘continuity and
sameness’ in one’s own eyes while being aware of the being in the ‘eyes of others’” (Erikson, 1950). This event
cracked the foundation for the client to enter into this next phase of adolescence with the hope of creating
identity. Instead, it did the opposite – creating an identity of separation racked with shame and guilt, which was
already built upon a damaged sense of attachment, leading him to his current phase of Isolation rather than
Intimacy. This continual pattern of the destruction of a foundational step rippling upwards is key to ongoing
development and can affect every ongoing stage of an individual’s lifespan (Malone, Liu, Vaillant, Rentz &
Waldinger, 2016).
Additionally, with this event occurring at age 10 to 11, as we look backward into the early stages, it is clear to
see the effect an event like this would have on the three previous stages – Trust vs. Mistrust, Autonomy vs.
Shame and Doubt, and Initiative vs. Guilt – threatening any progress or internalization of these concepts that he
had made up to that time.
Erikson, E. (1950). Childhood and society. New York, NY: W.W. Norton.
Malone, J.C., Liu, S.R., Vaillant, G.E., Rentz, D.M., & Waldinger, R.J. (2016). Midlife Eriksonian psychosocial
development: Setting the stage for late-life cognitive and emotional health. Developmental Psychology, 52(3),
pp. 496-508.
Promoters:
Unfortunately, due to the nature of the client’s patterns and emotions, his promoters were scattered
throughout his environment which he was unable to distance himself from, due to the natural consequences of
his behaviors. Primarily, his promoters during the increase of symptoms, substance use and eventual suicide
attempts were the relationships with his family. Client states that time with his family, although they attempted
to be supportive, only served as reminders of earlier childhood trauma and the expectations that he felt he
wasn’t living up to and couldn’t live up to, no matter how hard he tried. The further his substance use
increased, the more doors were closed, opportunities were lost, and need was created, which drove him back to
his family as his only resource and option. This perpetuated his patterns of behavior, resulting in the increased
frequency and severity of his symptoms. Throughout the sessions, this is an area that is showing improvement.
Removal of access to sources of maladaptive behaviors has allowed him to approach his feelings with support.
This has also begun to open the door to restoring a dynamic of relationship with his family, potentially for the
first time ever.
Recent anxiety triggers have emerged surrounding his first suicide attempt. Client walked through an episode in
detail involving the cutting of chicken in the kitchen at the facility where he resides. Witnessing this episode
created feelings of anxiety and fear, physical symptoms of shaking and sweating, and he had to remove himself
from the area in order to keep himself from acting out and to calm down.
Protective Factors:
Although the client does attribute a number of his different symptoms and current feelings and anxieties with
his family, which existed in and around a church, he does maintain a very firm and strong relationship in
Christianity as his core values and beliefs and guiding principles. He is extremely knowledgeable in the faith and
its practices, giving him a wide range of coping mechanisms which he has begun to incorporate back into his life
– prayer, meditation, worship through singing and relationship with other practicing Christians as support.
Client states he will use this in times of feelings of strong anxiety and crisis but is also beginning to incorporate it
back as a practice into times of more consistency as well.
Client also states that he has begun to put into practice other coping skills as well – removing himself from
troubling situations when he feels pressure or anxiety, a more balanced diet, incorporating workouts, and
spending more time with others in relationship rather than isolating and being forced into events. Currently he
is in a controlled environment which offers ease of access and availability to all of the above factors. As he
progresses the emphasis will be on life after treatment and how he will be able to incorporate these into his
own structure and routine.
Medical History:
Current knowledge of client’s medical history surrounds the more recent crisis and trauma events only. At this
time, I am currently unaware of any other major medical events or issues.
Summer 2019 was the first 30-day treatment program located in Florida, sponsored by his parents. Prior to
that, there had been numerous short-term hospital stays for detox and alcohol poisoning. At the beginning of
May of this year, following his first suicide attempt, client was hospitalized short-term within the psych unit and
then prescribed aftercare which was not followed. Following his second attempt, client was committed to the
psych unit for a second time, again for a short-term stay and detox.
Career Status/Needs:
Client has expressed a clear desire to “feel better and live a different life,” which includes returning to
furthering his education and finding a career path. After graduating high school, he had a number of short-term
positions, but had a desire to attend college for dentistry. He eventually applied, was accepted and began the
initial core semester, but was forced to withdraw due to his use and legal issues. Most recently, client was
employed by an HVAC company in the Des Moines area and found it enjoyable, he has expressed a desire to
pursue it as a career. Client is intelligent, well-mannered, capable and motivated, and is beginning to rebuild a
support structure of family around him to help maintain his direction. Current obstacles involve the severity
and frequency of presenting symptoms of depression and anxiety which in the past have led to behaviors
damaging his work life. Goals will need to include the correlational factors between self-care, coping skills, and
other life areas such as work and relationships.
Co-occurring Disorders:
Client has been previously diagnosed with depression/anxiety and substance abuse disorder, based on previous
events. At the current time, in addition to major depressive disorder with suicidal ideation and alcohol use
disorder-severe, he also meets the criteria for post-traumatic stress with panic attacks, taking into account
recent experiences surrounding the flashbacks and acute stress response to memories of his first suicide
attempt. Additional factors to consider for major depressive disorder is the beginning stages of the diminishing
frequency and severity of his symptoms, however the timeframe for duration and severity still applies due to
recency. Similarly, while the alcohol use disorder is qualified by early remission in a controlled environment,
client has no recollection of the last time he was able to maintain sobriety for any length of time while on his
own.
Current stage of change would be classified as Preparation moving to Action, by displaying a commitment to
long-term treatment and beginning to show signs of progress in mood, outlook and coping skills.
Cultural Considerations
Cultural Identity:
Utilizing the ADDRESSING model:
A – 24
D – No congenital/developmental disabilities
D – No acquired disabilities
R – Identifies as Christian
E – Caucasian
S – Lower/Lower Middle Class
S – Heterosexual
I – English/Scottish
N – U.S. born
G – Male
One of the client’s strongest factors currently is the reoccurrence and integration of his Christian faith into his
daily routine and activities. Client has stated that for a number of years, he went away from his faith
consciously, not out of dislike for the faith but due to the reminding factors of his childhood trauma and the
association with his family identity and the relationship with his parents. Currently he finds that this aspect of
his identity has become one of his strongest identifiers and has reestablished itself within his core values and
beliefs. Upon entry to his current inpatient stay, he found that his parents’ congregation took up a collection to
help defray the cost of his stay, which impacted him greatly. He has expressed a desire to return to the church
during a visit day and thank them in person for their support. This is in conflict with some of the stated feelings
from his time growing up in the church, the pressures and expectations he felt and the relationship with his
parents (as pastors) at that time. Client identifies as Caucasian American, with no strong identifying factors
from his indigenous heritage other than knowledge of ancestry. Client’s childhood and adolescence was in a
predominantly Caucasian area of Des Moines and was in close relationship with those of a similar cultural
background – and specifically faith background – as his own.
Cultural Stressors:
The primary cultural struggle of the client was the family environment and structure in which he was raised, and
the effect that he felt that it had. As a son of church pastors, his expressed feelings were of being watched
constantly by others, the need to live up to an unachievable standard, the need to be an example for others,
and also that his options and directions were limited, and possibly predetermined by his parents’ expectations.
According to a Washington Post article (Burke, 2013), studies show that most pastors’ kids struggle with issues
of identity, privacy and morality. Israel Levitz, in his book, “A Practical Guide to Rabbinic Counseling” (2005)
says that “it is well known that the higher expectations placed upon children of clergy create for them
inordinate difficulties in growing up.” These stressors instilled a stated feeling of needing to “wear a mask,” at
all times, stifling his ability to learn to share emotion, to express difficulty, to gain and feel true intimacy, and to
feel truly included and loved. Because of this feeling of needing acceptance based on appearance and stability,
the client experiencing trauma at age 10-11 would have left him feeling as though he had nowhere to turn, as
evident by his withholding this experience until the present. To share this information at that time would have
been perceived as bringing guilt and shame upon his parents, his family, the church and the community, due to
the inherent pressure he felt. This further drove his feelings of isolation and cemented his feelings of lack of
acceptance and lack of identity.
Additionally, traditionally speaking most small church leaders are compensated in non-traditional ways – most
commonly a smaller, traditional paycheck or stipend, in addition to housing in a parsonage if available along
with potential food supplies from donations to the church or food bank to assist. In a family of 6 on the salary
from a smaller church, client expresses he would consider himself lower class – possibly lower middle at best.
He expressed that these two factors affected a majority of his relationships during his early formative years, as
qualifiers from kids about who he was – affecting their judgment and treatment of him. He has stated that a
majority of his time and relationships came from within the church. When he began to stray away from these
relationships and was left to discover his own – through school and work – he gravitated towards other
marginalized individuals, encouraging him to adopt a more negative lifestyle with negative habits and patterns.
These then became his coping skills.
Another major factor of his marginalization was the experience of early childhood abuse, which he is just now
beginning to process through. While not shared with anyone, the internal marginalization and self-labeling,
stemming from the guilt and shame, works as a cultural stressor based on the perceived image of those who
have spoken out about their abuse. These feelings only worked to drive his emotions further inward and force
him to “wear the mask” even more.
Client is a Caucasian male, and although there is an inherent white male privilege to consider, based on his time
from late adolescence through to the present day and the behaviors and choices he has made, his
consequences have worked to erase a number of different opportunities and available options he may have
once had. One aspect to consider is that the area of town where he grew up is traditionally lower to lower
middle class with some of the highest crime and drug rates in the city. For that area as the son of pastors, there
may have been some relative affluence to consider, along with the accompanying sense of privilege amongst
the community.
Burke, D. (2013, May 2). Beneath stereotypes, a stressful life for preachers’ kids. The Washington Post.
Retrieved from https://www.washingtonpost.com/national/on-faith/beneath-stereotypes-a-stressful-life-forpreachers-kids/2013/05/02/7de61a8c-b367-11e2-9fb1-62de9581c946_story.html
Levitz, Y.N. & Twerski, A.J. (2005). A practical guide to rabbinical counseling. Jerusalem: Feldheim Publishers.
Cultural Influencers:
His parents’ church is located on the east side of Des Moines. Traditionally this is one of the less affluent areas
of town – a majority of the growth has gravitated outward from downtown and mostly west. The east side has
seen relatively little growth and is stagnant in economic development. It is also traditionally the part of the city
with the highest crime and drug rates. Demographics include primarily Caucasian with some small pockets of
ethnic communities – Italian American, Mexican American, Asian American – with a very small percentage of
African Americans. During his early childhood years, client has stated that being in that environment wasn't as
known to him due to the sheltered structure of his family. However, when his relationship with his family was
splintered and he was left to his own devices, the sources of negative patterns were all around him.
Also, the east side of Des Moines is traditionally seen as a community in and of itself within the Des Moines
area. Some areas use the suburban title to state where they’re from – Waukee, Johnston, West Des Moines.
“East Sider” is known as its own label and traditionally its own smaller subculture within Des Moines. This
identity stands apart from the other areas of Des Moines and creates a separation within itself from other
communities, from a biased, if not prejudiced, standpoint. Individuals from the east side do not think highly of
those individuals from the more affluent west side of town. In contrast, they think more highly of themselves
than those individuals living in the inner city. This identity and cultural influence contributed to reinforcing the
sense of identity isolation for the client, one in which he was already stuck.
Eventually once he fell further and further into his addictive behaviors, he began to feel more and more labeled
by those around him, including some of his family members. He stated that looking back he knows that his
parents were trying to support him, but at the time he felt ostracized by everyone around him, regardless of
their efforts to reach out. Additionally, once he was arrested multiple times and had been to treatment, those
in his social and cultural group began to label him as the “addict” and the “felon,” adding further to his
separation.
Personality Patterns:
Although struggling with a number of symptoms and current/past issues that have affected his overall
emotional state, client is a bright, well-spoken young man. My experience of him has been that of an
emotionally open individual, possibly for the first time in his life. Over the course of 6 weeks and 4 meetings I
have seen him make marked progress on his overall hope and outlook towards his future. While still carrying a
number of different things, he has stated that for the first time in a long time he is beginning to see that there
are options for him. His faith has become an important part of this new direction and he has stated that he
wants it to become a more prevalent part of his identity and culture as well.
Along with these positive traits do come the thought patterns which have dominated his life for a number of
years – flashes of worthlessness, feelings of insecurity and not living up to expectation, anxious tendencies – all
evident through the conversation in session about himself and his own life. These traits will be the target of
treatment goals as part of a holistic approach to his most urgent needs.
Implications for the Counseling Relationship:
There was a natural rapport built during our initial session simply based on familiarity of background and a
shared Christian faith. Based on that rapport, I believe the client saw me as a therapist he could trust rather
than some in the past which he hadn’t, and that allowed him to freely open up and speak during our first
session, at times speaking of issues for the first time ever. As the relationship has gone on, we have been able
to build on more cultural similarities – parts of town we knew, churches we both knew of, and other local
examples.
From a self-disclosure standpoint, I too am a survivor of childhood sexual abuse and have been able to
personally identify with some of the identity struggles the client has experienced, as well as some of the
maladaptive patterns and negative coping mechanisms that come with it. While I haven’t gone into any level of
detail about my experiences with him, I did feel comfortable self-disclosing to him during his initial discussion –
not only in an attempt to normalize the feelings, but also to alleviate some of his anxiety and pressure, knowing
this was the first time in his life that he was sharing that information. I also realize that while our overall
experience may be the same, the circumstances and details are vastly different, so I plan to take care when
interpreting his experience, if and when he feels comfortable to fully share and explore.
One difference in the lens I will need to use is the pressure of expectation of being a pastor’s kid growing up and
the implications that has for the family dynamic and identity development. I grew up in a household where I
was encouraged to explore and be who I wanted to be, regardless of parental expectation or cultural pressures.
In that regard, I have worked to ask the client as much as possible about his thoughts and feelings at that time. I
have appreciated the fact that he has been open and honest in sharing transparently about that type of lifestyle.
Ethical Considerations
ACA
B.1.c – Respect for Confidentiality
Counselors protect the confidential information of prospective and current clients. Counselors disclose
information only with appropriate consent of with sound legal or ethical justification
B.4.b – Couples and Family Counseling
In couples and family counseling, counselors clearly define who is considered “the client” and discuss
expectations limitations of confidentiality. Counselors seek agreement and document in writing such
agreement among all involved parties regarding the confidentiality of information. In the absence of an
agreement to the contrary, the couple or family is considered to be the client.
C.2.d – Monitor Effectiveness
Counselors continually monitor their effectiveness as professionals and take steps to improve when necessary.
Counselors take reasonable steps to seek peer supervision to evaluate their efficacy as counselors.
C.2.e – Consultations on Ethical Obligations
Counselors take reasonable steps to consult with other counselors, the ACA Ethics and Professional Standards
Department, or related professionals when they have questions regarding their ethical obligations or
professional practice.
C.7.a – Scientific Basis for Treatment
When providing services, counselors use techniques/procedures/modalities that are grounded in theory and/or
have an empirical or scientific foundation.
AMHCA
I.2 – Confidentiality
Mental health counselors have a primary obligation to safeguard information about individuals obtained in the
course of practice, teaching, or research. Personal information is communicated to others only with the
person’s consent, preferably written, or in those circumstances, as dictated by state laws. Disclosure of
counseling information is restricted to what is necessary, relevant and verifiable.
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I.2.b - The information in client records belongs to the client and shall not be shared without
permission granted through a formal release of information. In the event that a client requests that
information in his or her record be shared, mental health counselors educate clients to the implications
of sharing the materials.
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I.2.l - In working with families or groups, the rights to confidentiality of each member should be
safeguarded. Mental health counselors must make clear that each member of the group has individual
rights to confidentiality and that each member of a family, when seen individually, has individual rights
to confidentiality within legal limits.
B.1.a – Counseling Process
Mental health counselors and their clients work jointly in devising integrated, individual counseling plans that
offer reasonable promise of success and are consistent with the abilities, ethnic, social, cultural, and values
backgrounds, and circumstances of the clients.
C.1.j – Counselor Responsibility and Integrity
Take appropriate steps to rectify ethical issues with colleagues by using procedures developed by employers
and/or state licensure boards.
D.2 – Interpretation and Reporting
Mental health counselors respect the rights and dignity of the client in assessment, interpretation, and
diagnosis of mental disorders and make every effort to assure that the client receives the appropriate
treatment.
On the topic of confidentiality, regarding the client’s statements regarding his past sexual abuse – after further
consultation with supervision and some additional research, it was determined that Iowa law is non-specific
when it comes to a specific mandatory reporting timeline or statute of limitations on the distance between the
event and the present. Based on an article found from the APA (cited below), the legal response given to a
therapist in a similar situation was that they had the “discretion to report.” However, the following opinions
given from those consulted outlined the different ethical dilemmas that may arise based on the role the
therapist plays. Ultimately the duty is to the client within session under confidentiality. If/when the client
determines a desire to confront or challenge their accuser, it is up to the therapist to continue to maintain their
role to their client, rather than become an advocate or mediate/validate during any interactions. Ultimately,
duty to the client prevails and as the article states, “the psychologist (should)…use the therapeutic relationship
as a vehicle to empower the client.”
American Psychological Association. (2002). Ethics rounds: Reporting past abuse, part II. American Psychological
Association, 33(7), 90.
Legal Considerations
There are two legal considerations to consider with this client. First, at present, client is able to participate in
his current program at the discretion of the court, as he has been released on bond. His current charges are a
2nd and 3rd OWI, received within two days of each other. My client has consulted with his attorney who is
confident he can utilize an Iowa statute which allows for a “Second 2 nd” in certain instances, limiting the scope
of punishment for those willing to seek help (A 3rd OWI in the state of Iowa is a felony and carries a mandatory
1-year term in state prison). Assuming that is successful, client will most likely be able to continue treatment
uninterrupted, and any sentenced jail time will be suspended as time served based on his time within the
residential program. If not, there would need to be other considerations taken for his continuum of care.
Regarding any mandatory reporting statutes or guidelines surrounding his disclosure of past sexual abuse – as
outlined above in Ethical Considerations, there is no duty to report at this time in the State of Iowa, based on
the current statutes as written. Any legal action to be taken would need to be initiated by the individual client,
rather than a responsible third party. If that becomes the desire of the client, my responsibility would be to
become ethically compliant and continue to follow guidelines as dictated by the ACA/AMHCA, while continuing
to serve the client in the best way possible.
Theory-Driven Case Summary:
Client is a 24-year-old Caucasian male from Des Moines, IA. He is currently participating in a long-term
treatment program – he has completed 2 months of a 12-month long treatment course. Client had a recent
relationship with his girlfriend who he had been with for the previous year. Unfortunately, due to his recent
struggles with substance use and the legal system, along with his participation in long-term treatment, they
separated. She is an elementary school teacher who took a job about a 2-hour drive from the Des Moines area.
They did agree to stay in touch and determine if there is any relationship possibility in the future. Client did
graduate high school and had career aspirations of becoming a dentist – he was able to begin the first semester
of the undergraduate work but was unable to complete the requirements due to his substance use. Most
recently he has been on staff at a local HVAC company, but was fired within the last 3 months due to
legal/substance use issues.
Client has two older siblings – brother and sister – and one younger brother. His parents are both married and
pastor a small Evangelical church on the east side of Des Moines. His parents originally met when his father was
a police officer on the south side of Chicago. After 5 years, both of his parents woke up after having the same
dream of being called into ministry. They chose to follow this calling and moved to Eugene, Oregon where his
father attended bible college. Client was originally born in Oregon and spent his first 7 years there before the
family relocated to Des Moines when his father took over the pastor duties at their current church. Client has
expressed interest in returning to Oregon, either to visit or live.
Client describes his family life growing up as structured and rigid being a “pastor’s kid.” He expresses feelings
from his childhood that he always felt as though he was being “watched” by others within the church, in
addition to his own family. He felt the need to be an example, and he felt pressured into high, and sometimes
unachievable, expectations from others which drove his own expectations higher. At times he felt as though his
options were limited regarding choices of career, friends, and in other areas, and that his direction would be
pre-determined for him by his family. Early in childhood he had aspirations of attending college, which
eventually turned into his desire to go into dentistry, which unfortunately failed.
Client has shared that from the ages of 10 to 11, he experienced sexual abuse at the hands of an “older male”
within the church. This was shared during our first session together and client stated that this was the first time
he has ever shared any details of this experience with anyone. While not yet fully processed emotionally, client
states that he felt guilt and shame, worthlessness and feelings of powerlessness from this event, and is able to
connect this event to a turning point in his life with regard to emotional shut down, isolation, maladaptive
patterns and unhealthy coping skills.
Client states that alcohol and tobacco use began at age 14, with experimentation in marijuana use on and off
throughout his teenage years. He states he experimented with other substances – primarily methamphetamine
– but it was never any sustained use. Client received his first Operating While Intoxicated (OWI) charge in 2014.
He fulfilled all requirements and completed all recommended treatment sessions yet continued his previous
drinking habits. Over the next 4-5 years, client held various different jobs, attempted to return to school, and
had various relationships, none of which he was able to maintain due to his substance use patterns.
In the summer of 2019, his parents sponsored him to attend a 28-day rehabilitation facility located in Florida,
which he completed. He relapsed almost immediately upon his return to Iowa and did not follow through with
any of the aftercare plans.
In early May of this year, client had lost his apartment due to his use and nonpayment of rent and was living at
his parents’ home. During a time of heavy alcohol use, he got into a verbal altercation with his parents. He is
able to recall the event even though he was intoxicated. He states that he was experiences deep feelings of
worthlessness and guilt for the status of his life at the time and was extremely angry with his parents. During
this fight, client retrieved a large knife from the kitchen and slit his left wrist directly in front of his parents.
Client can recall specifics about this event vividly – blood spraying on all of them and on the wall, the size of the
knife, his parents’ reactions. His parents were able to administer immediate first aid and transport client to the
hospital where he was admitted to their inpatient psychiatric unit for monitoring and care. Following a short
stay and limited treatment, client was discharged and admits to not following any of the aftercare plans.
Shortly thereafter he resumed his previous substance use patterns.
Because of this return to use, his parents requested that he leave their home, with the only support being an
open invite to the family dinners, with boundaries on when he could arrive and when he had to leave, and that
he had to be sober. Client spent a number of nights living in his car before moving in with a family from his
parents’ church, where he continued his patterns. Shortly thereafter, during a binge episode, he found himself
walking along a highway in Des Moines speaking with a family member on the phone, stating that he was going
to jump in front of a truck. He was eventually picked up by the police and transported to a local hospital, for a
second inpatient psychiatric stay. Following this stay he transitioned directly to the long-term program where
he currently resides.
Client, while very open to conversation about thoughts and emotions, currently displays difficulty finding
positive aspects about himself. He still clearly expresses feelings of worthlessness and guilt almost every day,
especially now after a time of sobriety and clarity giving him perspective on the wreckage behind. Upon sharing
his traumatic abuse experience, client expressed deeper feelings of worthlessness with powerlessness and
shame. In one instance, during our first meeting, he stated that he refers to himself as a “garbage can” because
he can be used for a variety of different purposes.
Client also describes clear symptoms of anxiety in times of confrontation or conflict, but extreme symptoms
surrounding events which trigger memories of his suicide attempt. He described an incident in the kitchen at
the facility where he resides currently, which involved another individual cutting up chicken with a large knife.
At the sight of the knife and blood, he began to feel extremely anxious and nervous, began to experience
physical symptoms – shaking, sweating – and eventually had to remove himself from the situation to calm
down. He is able to utilize certain coping skills which he has begun to integrate in an effort to alleviate the
feelings and symptoms – prayer, meditation, worship music. He does display some minor signs of avoidance
with this event as well, as he wears a large wristband on his left wrist to cover the scar. He does acknowledge it
however and stated that it helps keep people from asking a lot of questions.
Overall, client has a generally calm and quiet temperament. He expresses that his personality is night and day
different than when under the influence of substances, however. He currently has no set plans for the future
regarding career or life path and has said that he is wide open and excited about a new direction. He selfassesses a clear indication of “rock bottom” and has a strong desire to address the problems from his past. He
is open and willing to share circumstances and details from his past, able to identify and express emotions, and
is successful in employing coping skills and safety plan items.
Key issues would include:
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Depressive symptomology leading to suicidal ideation and attempt – feelings of worthlessness, guilt,
shame, isolation/separation
PTSD/Acute stress response symptomology resulting from his recent suicide attempt
Lack of clear sense of identity/purpose
Unprocessed trauma and emotional/developmental impact from childhood sexual abuse
Repressive childhood environment, leading to isolation and marginalization throughout development
resulting in deficiencies in intimacy and emotional expression/processing
Looking at my own theoretical orientation of REBT/Adlerian, the primary task would be to drive below the
surface of the initial presenting behaviors, once those are addressed as the urgent need and the proper safety
measures put in place. Secondly, both his behaviors and expressed emotions then give us an inroad to the
client’s core belief structures – self talk, core values, beliefs about himself, beliefs about the world. At that
level, we can begin to trace back the beginning root causes of those maladaptive beliefs which he is desiring and
able to discontinue. From the roots of the beliefs, we can examine the nature of what is possible to believe
differently, what he will choose to believe differently, and how that can have a ripple effect throughout the
emotional and behavioral levels above.
From an Adlerian viewpoint, the client’s family structure has unfortunately worked against any kind of
attachment, validation, connection or encouragement. Through the client’s eyes, the needs of the image of the
family far outweighed his ability to share or the importance of his own emotional struggles. His sharing of
feelings of expectation, feeling as though he was being watched, feeling as though his future was going to be
determined for him – these all began to play against any type of self-validation. Client has expressed that he
can actively remember having to “put a face on” around his family and church members, learning to
compartmentalize his own feelings and identity in favor of the one he felt was desired – not to mention the one
he felt he could never fully live up to. This stunted his ability to make healthy familial connections through
validation and significance, instead feeling discouraged and put on display.
Once we reach the moment of traumatic abuse at age 10-11, what was already beginning to take root was
further solidified and cemented into his core beliefs – feelings of guilt, separation, and even further isolation
with nowhere to turn. Because he was never able to fully process those feelings at the time, there was no hope
for reconciliation and further marginalization through the remainder of his developmental years was almost an
inevitability.
If we consider Erikson’s perspective, it only works to reinforce this perspective, as this occurring in the stage of
Industry vs. Inferiority would have driven home the point that the client was inferior to those around him. Not
only was he not able to live up to his perceived standards, but now he was completely separated by traumatic
experience, one which he felt he could not share out of fear of guilt and shame. This set the stage for the
remainder of his adolescence and into young adulthood, setting maladaptive patterns throughout concepts of
attachment, intimacy and emotional processing. It also called into question all that may have been established
from that point backwards as well – mistrust, shame/doubt and guilt, rather than trust, autonomy and initiative.
As we incorporate that view into an REBT perspective, this developmental pattern created a network of
negative core beliefs during the heart of his developmental years, which would drive his thought patterns and
worldviews through to the present day. As these negative core beliefs – I am worthless, I am different, I can’t
tell anyone, I’ll never live up to expectations – continued to solidify, they drove his emotional state further and
further into the depressive symptoms we see today - Feelings of worthlessness and guilt, separation and conflict
within his family, a desire for intimacy yet a need to stay isolated. All of these emotions, combined with his
childhood development deficiencies creating a lack of skill sets, drove him to the maladaptive behaviors of his
community and the cultural influence around him – primarily substance use and abuse. This pattern worked in
a cyclical nature and was only exacerbated by itself as it continued to spiral into further and further issues,
ultimately resulting in an act designed to bring about the ultimate separation and isolation – suicidal ideation
and eventual attempt(s).
Client displays a number of strengths which contribute to his overall potential for success – willingness and
motivation to change, desire for a positive outcome, desire to rebuild positive relationships, emotional
awareness. Client has already committed two months towards positive growth and is remaining in current
treatment on his own volition. Treatment will provide for long-term care and after care support – 1-year
inpatient, 1-year accountability support, and ability for involvement ongoing. Client also has a strong support
structure in family which is rebuilding relationship – while this dynamic will require further work from the client,
the goal is to restore a healthy boundary system and dynamic which will strengthen his support team.
Currently, barriers to the client’s success are partially limited, due to his residence in a full-time facility. While
this will act as a strength for the time being, the barrier will present itself as he begins to reintegrate into
society/life during the latter stages of inpatient care. At that time, as client begins to face increased trigger
points and potential for increases in anxiety and stress responses, the hope is that the work to that point will
have addressed core issues and equipped other skill sets to a point of stability and created a successful path to
handle the stimuli. Additionally, while the client’s familial relationships are continuing to be rebuilt, at this point
it is still a situation in flux and there are still a number of dynamics to address. The client’s younger brother and
the youngest of the family is also currently participating in a substance use/abuse lifestyle, which may bring
about feelings and trigger points as client reintegrates to the family in a healthier way.
Summary of Conceptualization Presented to the Client:
After four sessions, I first just wanted to thank you for sharing your story with me. I know it’s never easy to
share personal stuff for the first time in a new relationship, especially personal information that sensitive and
difficult. I appreciate you sharing your life with me and allowing it to be part of our work together.
As I started looking at all the different things you shared – how you felt growing up within your family, the
trauma you experienced as a child, the feelings you shared as you continued to grow up and how you always
felt them getting worse, never better – I started to be able to see a connection from those experiences to how
you said that you felt, both then and now. Feelings of worthlessness, feelings of guilt and shame, feelings of not
being good enough and not being included. And, as a result of those feelings, the desire to escape those
feelings and everything else through the drinking and drug use. Unfortunately, those only served to create
more struggle and at times made those feelings even worse. Those thoughts led to even more difficult thoughts
of ending your own life.
When I put that together, I see the process as: behaviors are driven by the emotions, which are then driven by
your core beliefs/thoughts/experiences. The behaviors you always wished you could stop but never could – are
fueled by the emotions which you’ve always felt. The emotions you’ve always felt – are fueled by the thoughts
you have which you learned from your experiences. If you felt isolated from your family – “I’m different.” If an
experience made you feel worthless – “I’m worthless.” If you never felt included and always emotionally
separate – “I can’t share my emotions with anyone.”
As we keep moving forward, one of the main goals is to continue the safety plan that we’ve started and the
coping skills which you’re already using, since those appear to be working well. Next, what I’d like to do is work
with you on identifying those core beliefs and thoughts about yourself, about the world, about whatever. Once
we can start looking together at where you began to first learn those things, then we can start asking questions
– do I really believe that, do I want to believe that, what do I believe now that I’m in a different place, think
different things, have different motivations?
Once we start to work on your core beliefs and you begin to change the way you see yourself, the world,
experiences – I believe that the momentum you’ve already started will begin to pick up and we’ll start to see
even more positive changes. You’ve already started to take action, now we just need to keep taking the next
steps together.
DIAGNOSIS
Primary Diagnosis and Justification:
296.33 (F33.2) – Major Depressive Disorder with suicidal ideation, recurrent episodes,
severe, with anxious distress
Client meets the following criteria:
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Depressed mood most of day, nearly every day
Markedly diminished interest in activities
Fatigue, loss of energy
Feelings of worthlessness, excessive guilt
Recurrent thoughts of death
While substance use disorder is present, client identifies feelings are consistent separate of substanceinduced episodes
Client has expressed all of the above in the first meeting and, while showing some signs of improvement,
continued symptoms of the above throughout each of the following three sessions. Prior to treatment, client’s
environment and relationships continued to exacerbate his symptoms, along with continued substance use.
Symptoms remain present within a controlled environment free from substances, hence no substance-induced
qualifier. Dysthymia was ruled out based on timeframe. While there was some consideration for a reordering
of the diagnoses, the urgency of the suicide attempt/suicidal ideation, coupled with the ongoing severity of the
symptoms of depression, identified Major Depressive Disorder as the primary diagnosis and the target of the
initial goals of treatment. Without establishing a firm safety plan and beginning to instill a sense of hope, any
work in the following two diagnoses and treatment areas would have been ineffective.
Assessments: No current assessments other than in session discussion. Prior diagnosis exists during previous
inpatient hospitalizations and current symptomology is consistent with previous diagnosis.
Secondary Diagnosis and Justification:
309.81 (F43.10) – Post Traumatic Stress Disorder with panic attacks
Client meets the following criteria:
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Directly experienced the traumatic event
Recurrent, intrusive distressing memories
Intense psychological distress at exposure to cues
Persistent avoidance of stimuli
Negative alterations in cognition and mood
Marked alterations in reactivity
More than 1 month in duration of event occurrences
Causes clinically significant distress
Not attributable to substance use – symptoms exist during periods of sobriety
Client has showed recurrent episodes of all of the above criteria in relation to his suicide attempt 2.5 months
ago, with some limited improvement over the previous 6 weeks. Client has described a distinct major panic
attack episode, alongside other minor triggers and smaller episodic events. Client exhibits avoidance of stimuli
by choosing to wear a wristband to cover the scar from incident. Client has noted that some symptoms from
episodes can last anywhere from 1 hour to 1 day following the episode and utilizes coping skills to alleviate.
Consideration for Acute Stress Disorder was ruled out due to timeframe from initiating event. Secondary to
safety plans and depressive mood with regard to treatment planning and will require additional therapeutic
techniques from a balanced emotional state to make significant progress.
Assessments: No direct assessments selected or administered at this time – diagnosis based on client
description of events during in session discussions.
Tertiary Diagnosis and Justification:
303.90 (F10.21) – Alcohol Use Disorder, severe, in early remission, in a controlled
environment
Client meets the following criteria:
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Consumes larger amounts of alcohol than intended
Multiple unsuccessful efforts to stop
Experiences cravings
Failures to fulfill major life roles
Has continued use despite major problems
Developed a tolerance to alcohol consumption
Continues recurrent use when physically hazardous
Client began using alcohol at age 14, progressing from occasional - casual - daily - dependent. Client’s primary
drinking patterns is moderate amounts daily with some binge episodes occurring with heavier amounts lasting
from 1 day to over a week in duration. Has experienced blackouts. Use has resulted in legal troubles – 1st OWI
in 2004, 2nd and 3rd OWI’s both in late May 2020. Client has participated in previous 28-day inpatient treatment
program and completed successfully. Relapsed shortly after completion and did not participate in any of the
aftercare activities. Will be in a controlled environment for the next 5+ months during long-term inpatient
treatment and will have limited passes outside the center, only with familial accountability. The final phase of
treatment will include regular scheduled employment, church and social activities. Prior to participation, goals
of treatment will include establishment of a safety plan and prevention/coping techniques. Consideration was
made for reordering diagnoses based on severity and duration – however, urgency of symptoms and safety risks
were taken into account.
Assessments: No direct assessments selected or administered at this time. Prior diagnosis exists during
previous inpatient hospitalizations and symptomology prior to current treatment is consistent with previous
diagnosis.
CLIENT-CENTERED GOALS
Goal 1:
Positively impact and minimize/eliminate current depressive symptoms and suicidal ideation.
Objective 1 of Goal 1:
Positively impact/adapt/change current negative core values and beliefs.
Intervention 1:
Utilize Automatic Negative Thought (ANT) assessment to identify current negative patterns of thinking, self-talk
and automatic negative processing. Determine first potential experience or first recollection of having that
negative thought in attempt to discover source. Establish rational vs. irrational and determine potential
acceptable alternatives.
Intervention 2:
Journal assignment of positive thoughts and negative thoughts about self. Examine for incongruencies,
inconsistencies, and differences/similarities with core values and beliefs for acceptable alternatives for
negatives and reinforcement of positives.
Objective 2 of Goal 1:
Identify and reinforce current positive character qualities, strengths and personal desires/hopes/aspirations.
Intervention 1:
Complete the 16 Personalities online assessment to determine client’s personality type. Review with client for
identification of strengths and categories of opportunity.
Intervention 2:
Journal assignment of 1-year and 5-year goals and aspirations. Assist client in developing SMART goals in order
to achieve their desired milestones.
Objective 3 of Goal 1:
Examine current safety plan and determine changes or additions that need to be made, if any.
Intervention 1:
Determine effectiveness of current coping skills and safety techniques utilized during recent stressful and/or
anxious events. Brainstorm for any additional coping skills to be identified and incorporate into safety plan.
Goal 2:
Development of a manageable, ongoing plan for abstinence from alcohol and other substances.
Objective 1 of Goal 2:
Identify current sources of stressors and triggers which have led to past substance use.
Intervention 1:
Utilize “Triggers” worksheet as homework to identify triggers specific to client’s culture and environment.
Develop safety plan for identified trigger points.
Objective 2 of Goal 2:
Identification and elimination of harmful self-talk/self-thoughts based on positive/negative list from Goal 1.
Intervention 1:
Homework assignment which identifies examples of negative self-talk, identifies faulty logic/irrationality in the
items, creates alternatives and begin to incorporate into practice.
Objective 3 of Goal 2:
Establishment of long-term safety plan/support network to utilize beyond the duration of current treatment.
Intervention 1:
Homework assignment which establishes a list of individuals that client can call in times of crisis or trigger. This
list may include supportive friends, family, clergy, groups, sponsors, facilities, or other. List will be reviewed
together to ensure appropriateness of individuals included.
Intervention 2:
Brainstorm for any additional coping skills to be identified and incorporate into safety plan.
Goal 3:
Identification, evaluation, and processing of emotional pain, grief, shame and trauma surrounding past
occurrence of sexual abuse.
NOTE: This goal will only be attempted in the event client determines he is ready to fully approach this subject
in depth. Until then focus will be placed on Goals 1 and 2 with the intention of progress developing the
emotional stability for client to discuss the past trauma.
PROGNOSIS
Have completed four sessions with client to date. From the first session on, client has presented as emotionally
open and honest surrounding past events, current emotions, and has been transparent in his desire to work
towards growth and progress in each of the above areas. From session 1 to session 4, client has begun to make
progress in coping skills, overall demeanor, hope and outlook on life, establishing new relationship dynamics
with family and self-awareness and identification of emotions. Based on responses to in-session discussions and
motivation to change, along with current safe environment, overall prognosis is good for continued progress,
skill development and symptom reduction.
Reevaluation of Treatment Plan
Treatment plan to be re-evaluated at 90-day mark for effectiveness and any potential changes.
Clinical Note:
Client: Male, 24 years old
Data: Client is currently in an inpatient treatment facility for uncontrollable substance use/abuse and
depression, both of which have been previously diagnosed. Client describes his pattern of substance use
beginning at age 14 with use of tobacco and alcohol. This continued as what he described as “casual” use until
after high school, when occasional use increased to every day, and eventually to physical dependence with
binge episodes, lasting anywhere from a few days to over a week. Client notes that the increased use
corresponds to his increase in feelings of guilt and worthlessness every day. Client experienced a suicide
attempt in May 2020. Client was committed by his parents to a 30-day treatment program in Florida. Following
treatment, client’s use pattern continued, and he received both 2 nd and 3rd OWI charges within a 2-day span.
Second suicidal event was shortly thereafter, threatening to jump in front of a truck from the side of a highway.
Following this episode client was hospitalized and sought help in long-term treatment. Client also shared during
initial session that he experienced sexual abuse at the hands of an “older male” from the ages of 10 to 11.
Client states that growing up he always felt watched, experienced feelings of unrealistic expectations, and
eventually felt separation from his family due to his behavior patterns and use. He expressed feelings of guilt,
shame, powerlessness and worthlessness as a result of his childhood abuse. Client also stated recent
experiences of anxiety and physical response due to triggered memories of his first suicide attempt. He
expresses a clear desire to address his depressed mood and substance use – wanting to “feel better and live a
different life.” He also desires to eventually address his previous abuse experience in more detail when ready.
Assessment: Primary – Major Depressive Disorder with suicidal ideation, recurrent episodes, severe, with
anxious distress. Secondary – Post Traumatic Stress Disorder with panic attacks. Tertiary – Alcohol Use
Disorder, severe, in early remission, in a controlled environment. Key issues include depressive symptomology
leading to suicidal ideation and attempt – feelings of worthlessness, guilt, shame, isolation/separation,
PTSD/Acute stress response symptomology resulting from his recent suicide attempt, lack of clear sense of
identity/purpose, unprocessed trauma and emotional/developmental impact from childhood sexual abuse,
repressive childhood environment, leading to isolation and marginalization throughout development resulting
in deficiencies in intimacy and emotional expression/processing. Client’s development included overwhelming
cultural influence from family structure as a “pastor’s kid,” including feelings of pressure to perform,
expectations, insufficiency. Combined with sexual abuse at age 10-11, client was further driven into feelings of
isolation, repressed feelings, marginalization and eventual self-exclusion from the family and church. This
exacerbated current symptomology and increased occurrences of maladaptive behavior and substance use.
Cycle continued to promote itself into increasing levels of consequence, resulting in consistent suicidal ideation,
the first suicide attempt, and the threatened second suicide attempt. Client is currently very open to exploring
the root causes of his issues and desires life change, along with establishing a safety plan and coping
mechanisms.
Plan: Positively impact and minimize/eliminate current depressive symptoms and suicidal ideation by
identifying core values and beliefs, reinforcing positive strengths and character qualities, and
establishment/continuation of effective safety plan. Development of a manageable, ongoing plan for
abstinence from alcohol and other substances by identifying current stressors and triggers, targeting and
replacing harmful self-talk and self-thoughts, and establishment of a long-term safety plan/safety network.
Additionally, if and when client is prepared: Identification, evaluation, and processing of emotional pain, grief,
shame and trauma surrounding past occurrence of sexual abuse.
Evaluation of the Agency/Program
Description: New Life Counseling and Coaching, under the supervision of Dr. Don Gilbert, is a faith-based
professional counseling office, providing professional counseling and coaching services to individuals, couples,
families, churches, businesses, group and organizations for more than 25 years. Staff includes clinicians who are
trained in the fields of psychology, mental health counseling, marriage and family therapy, and social work.
Goals/Outcomes: New Life Counseling and Coaching’s goal is to help clients find solutions to life problems
that limit success.
Evaluation Methods: Provision of cognitive behavioral services from a Biblical foundation utilizes sound
psychological theory and interventions, based on the unique needs of the client, in order to assist achievement
of success both personally and professionally.
Results: Results are determined on a client by client basis depending on unique needs of the client.
Measurement of results vary based on stated goals of client, determined goals in session, and are measured
either by assessment or by self-assessment of client’s desired levels of achievement.
Justification: N/A
Recommendations: None at this time.