This report contains privileged and confidential patient information and may not be copied. Any unauthorized disclosure is a federal offense. Date of Report: 7/17/2022 Student’s Name: Patient Name: Don & Carol Richardson Gender: Don (M), Carol (F) Age: D(40), C(38) DOB: D(1/2/1982) C (1/3/1984) Marital Status: Married Occupation: acct firm mngr/admin assistant Dates of Treatment: 7/15/22 Session Number: 1 On the basis of the initial evaluation and therapy sessions with this client, it is my opinion that the information contained in this report is reliable and is likely to be a valid reflection of his/her current level of functioning outside of the examination setting. SOURCE AND REASON FOR REFERRAL Include the reason for the referral, as well as the referral source. Include symptoms and identified problems. AM and AF are having marital problems involving trust and commitment. AM works a corporate job, and AF is an administrative assistant in a similar corporate environment. AF claims AM is inattentive, untrustworthy, consistently looks for other women to pursue, and she believes he may already have had an affair. Suspicions are fueled somewhat from her observations and experiences with executives at work. AM denies claims and believes AF is overdramatic. Tension has erupted into fighting, sometimes in front of 3yo child. AF Sally was referred for individual and family therapy to help her gain a better understanding of her strengths and increase communication within her family. Mary was referred by her general physician, after complaining of symptoms related to depression and anxiety. CLINICAL EVALUATION This area assesses your ability to identify presenting problems and collect information to assess clinical issues and formulate a diagnostic impression within the client’s interpersonal and cultural context specific to the case. Clinical evaluation provides a foundation for therapy and provides the therapist with a unique lens in which to view clients’ problems. Clinical evaluation begins with the first contact with a client. The following elements are key components of a systemic case conceptualization: 1. 2. 3. 4. Who is the client? What is the essential background information? What is the assessment (from the theory you have chosen)? What is the client’s perspective? The clinical evaluation should include an assessment and diagnosis from your selected theories perspective. PRESENTING PROBLEM In this section you need to describe your client(s) and provide some background and contextual information about them. Do not add extra information that is not included in the vignette. Often we are given limited or incomplete information but need to use the information as it has been given and not add our assumptions to add “color” to the case. DESCRIPTION OF THE PRESENTING PROBLEM (as the client sees it). Include the relevant information about the presenting problem such as the history of the problem, its occurrence, frequency, contextual issues, etc. It is important to incorporate your client(s) own words in this section when describing the presenting problem. Again, don’t make assumptions in this section. You want to present the case accurately and from the client’s point of view. HISTORY OF THE RELATIONSHIP AND THE INDIVIDUALS (length and detail determined by the theory you are going to use for this assessment). In this section, you should discuss the relationships involved and provide some background and contextual information for your client(s) from what has been provided. ASSESSMENT The application of theory to data, or in other words, a description/analysis of the problem as YOU the therapist sees it, using the concepts, terms etc. of your chosen theoretical model. In this section, you need to discuss what is happening in the system using correct theoretical concepts and ideas. GOALS FOR TREATMENT According to your theory, what goals will you address in treatment with your client(s). When writing goals you want them to be short, succinct and measurable. How are you going to know progress is being made? Goals should also be written out in list form. THERAPY TECHNIQUES Address your overall plan for treatment. Include specific interventions from your chosen theory. This section should describe the exact interventions/techniques you would use and why. Be specific-relate the interventions to the client, their problems, and your assessment. DSM-V DIAGNISIS AND RATIONALE List diagnosis by number and provide rationale for client’s diagnosis, including symptoms and client’s report of symptoms. If appropriate, provide a differential process. Do not forget to diagnose each client you are treating in the treatment unit. Sally reports excessive worry and anxiety occurring more days than not for at least 6 months relating to a number of areas in her life including her family, her work, and her social network. Sally finds it difficult to control the worry as evidenced by how much time in a day she spends on worrying and how often the focus of the session is on discussing the things that worry her. Sally reports symptoms of restlessness, fatigue, irritability, and problems sleeping for over 6 months and states that she experiences these symptoms more often than not. Her symptoms are not due to a general medical condition as ruled out by her General Physician, nor from substance use/abuse, and is not a result of any other disorders. Sally states that her preoccupation with her “stress” has caused significant negative impact at work to which she has been placed on probation as well as alienated by her friends. Sally is diagnosed with Generalized Anxiety Disorder and not Acute Stress Disorder because she has not been exposed to a traumatic event that would have caused these and other symptoms; Obsessive Compulsive Disorder was ruled out because her excessive worry and anxiety are about real life events and problems and because Sally does not report nor seem to have compulsive rituals that she does to alleviate the worry. CRISIS ISSUES AND PSYCHOSOCIAL STRESSORS This area assesses your ability to identify, evaluate, and clinically manage crisis situations and psychosocial stressors specific to the case. This section should include the identification of any relevant past or current stresses and crisis issues. Evaluate severity of crisis situation, assess for trauma, risk factors, substance abuse, safety issues, sexual and/or physical abuse, domestic violence, child or elder abuse, and suicidality. Determine the impact on the client’s current life circumstances. Describe how crisis issues were managed. Include a discussion of client’s sense of hope, support systems, referrals provided and compliance with recommendations. Also discuss the implementation and management of safety plans. PROGNOSIS Discuss your projected outcome of therapy, given your approach, the client(s), and their problems. Include any process issues for the therapist (such as countertransference) and/or issues with ethical, legal, or moral ramifications. SELF REFLECTION Provide a brief self-reflection of your experience in completing this case report, why you like the approach that you used, how you see it useful, etc. - Self-object Relations Patterns o S-o patterns § How ppl relate to others based on expectations created by early experiences with primary attachments objects (esp mom) o parental introjects for client, SO, key fam members § internalized negative aspects of parents · ppl internalize and unconsciously strive to make all future intimate relationships conform to them (hear parent’s critical comments from partner) · become conscious and increase autonomy § Esp those patterns related to managing anxiety, criticism conflict, vulnerability, intimacy, etc - Defenses o Splitting § the “good” side of a person or thing as the part they find acceptable and the “bad” side of the person or thing as the part they find painful or unacceptable. often alternate between over-idealizing and devaluing the same person. o Projection/projective identification § falsely attributing one’s own unacceptable feelings, impulses, or wishes onto another (unaware) (cheating) § defense against anxiety by projecting certain split-off or unwanted parts of self onto another person o Repression/suppression § unconscious vs conscious repression of id’s innate impulses and drives o Minimizing: o Displacement § unconsciously redirecting intense emotion from a threatening object to less-threatening - Attachment Patterns o When clients feel securely connected in relationship, regularity of secure attachment, relational conditions for sec att o Atypical attmt behaviors when person does not feel secure in relationships: anxious, avoidant, anx-avo; frequency - Interlocking pathologies o Pursuing/distancing, criticizing/defending, controlling/resisting, other § Start of tension § Symptom escalation § Return to normal: § Expression of interlocking pathologies § Social location effects § Transference and repression - Justice and fairness: o foundation of intimate relationships; monitoring is constant, “just” is ideal and not attainable - Entitlements: o ethical guarantees to earned merits in relationships o Destructive: when children do not receive nurturing to which entitled and project this onto world (their debtors) - Invisible loyalties - Revolving slate o destructive relational process person takes revenge or insists on entitlements in one relationship based on another o Treats person as original debtor - Transgenerational legacy Attachments Defense mechs Justice/fairness Parental interjects Transference/projection Ledger Transgenerational legacies Revolving slate Goals for Treatment According to your theory, what goals will you address in treatment with your client(s). When writing goals you want them to be short, succinct and measurable. How are you going to know progress is being made? Goals should also be written out in list form. 1. Instill trust 2. ID attachment patterns 3. Correct projections 4. Establish expectations and needs 5. Create intimacy Wellness - Each person uses ego-directed action instead of defense mechanisms - Interactions in which dyad experiences intimacy without loss of self TIPs promote insight into PIPs across generations TIPs - Help clients examine how defense mechanisms maintain PIPs and encourage them to learn more authentically and directly connect with others Early: p288 - Increase awareness of S-O patterns and transference between couple/fam members and reduce splitting, idealizing, other defense strats to reduce conflict o Listen to and interpret S-O patterns and transference within system, and defense patterns related to conflict o ID where each person can take action to work through the assessed patterns Working: p 288-9 - Decrease interactions based on projections/revolving slate of entitlement to reduce conflict o Offer interpretations of projection patterns and revolving slate issues to increase each person’s awareness of dynamics o Use in-session examples of transference both between members and with therapist to help clients work through projection patterns - Reduce influence of neg parental introjects to enable authentic relating to reduce hopelessness and depressed mood o Detriangulation to separate neg pare interjects from interpretations and assumptions in current relationships o Identify 1-3 relationships in which client can work through neg par intjects - Increase autonomy and ego-directed action by making unconscious processes conscious to reduce conflicts o Elicit to develop client motivation to work in productive directions in relationship o ID areas of relationship which each member can work through dynamics to increase autonomy and goal-=directed action Closing p289 - Increase each member’s capacity for intimacy and mature love without loss of self to reduce conflict and increase intimacy o Interpret defenses and projections that hinder capacity of mature loge o ID opportunities for each member to work through issues that block capacity for intimacy - Develop reciprocal commitments that include fair balance of entitlements and indebtedness to increase capac... o Identify legacies, loyalties, and revolving slate patterns that have imbalanced current relationships o Examine ledger to ID more appropriate ad balanced calculations of what is due and owed Develop working therapeutic relationships Create holding environment that includes contextual issues as well as clients’ dynamics Work through client transference and monitor therapist counter transference Assess indiv, systemic and broader cultural dynamics ID each clients S-O relations patterns, splitting, projective identifications, repression, parental interjects and defense patterns ID interlocking pathologies, transference within system, ledger of entitlements and indebtedness, and each person’s capacity for mature love ID needed referrals, crisis issues, collateral contacts, and other needs Crisis assessment interventions: psych abuse, IPV, hidden affair, sub use Referrals: resources in community/family for support Therapy Techniques Address your overall plan for treatment. Include specific interventions from your chosen theory. This section should describe the exact interventions/techniques you would use and why. Be specific-relate the interventions to the client, their problems, and your assessment. Listen/empathy Interpretation and promoting insight Working through - Eliciting - Detriangulation - Fam of origin therapy
