Overview
Demographic Description of Client
a. 42, Female, white/caucasian, middle- lower class, heterosexua, Christian, Not married,some college education
B. Presenting Problem
a. Patient is referred through IOP she is currently in for Substance Abuse. Therapy is focused on past Trajma, PTSD , has gotten EMDR for trauma in the past but it didn’t work. Patient wants to explore current relatinal aspects caused by her trauma. Patient is mandated to attend group therapy , individual is optional
C. Interview Affect, Behavior, and Mental Status
Patient is well kept and has a positive / stable affect throughout the session.
D. History
a. Patients trauma beganwhen she was a child . She was sexually assaulted by biological father. Parents were bothinvolvedin the criminal justice system and were active meth users.
E. History of Presenting Problem
Presenting problem could be onset of substance abuse when she was 30. Trauma built up and got unbearable so patient started using drugs.
F. Family History
As stated above patient parents were active drug users and also sold drugs. Went to jail when patient was 16 and she had to take care of her 8 year old brother so he wouldn’t be taken by CPS (eventually got taken away til she was 18). Patients father sexually assaulted her.
G. Social Relationship History
Is currently in a healthy romantic relationship. Has a history of abusive relationships as well. Patient has trouble with maintaining and making female friends due to lack of trust and trauma caused from her mother.
H. Academic/Work historyN/A
I. Medical History
Main medical history isgoing through Detox for drugs
J. History of Previous Treatment
a. Previous treatment was mandatory due to patient being involved in car crash and she got a therapist for her case
K. Assessment/Diagnosis
a. Patient has PTSD andAnxiety
L. Treatment Plan/Recommendations
Make a treatment plan based off Symbolic Experiential , Narrative and Object relational therapy. Provide reasoning for each and sources.
M. What are the goals of therapy?
Please list specific short term and long term goals from a theoretical lens (3-5 is sufficient)
a. What methods should be incorporated (individual, group counseling etc)? What theoretical model are you utilizing? What type of interventions will be used (please list 3-5 interventions from a theoretical orientation)? What is the likely outcome if followed? What is the theoretical basis for interventions (affective, behavioral, cognitive)?
N. What Adjunct Services could be utilized?
no adjunct services O. What are relevant ethical and legal considerations regarding client, assessment, and plan? - if patient uses drugs again I am mandated to report it. The IOP she is in is 100% absinent. Patient has a history of being violent while she was using. If she tells me she is a threat to herself or anyone else I have a duty to report.
Please list ethical and legal concerns that are SPECIFIC to this case.
P. What is prognosis (favorable, marginal, good, excellent, etc.)? What makes you think so? Good bc patient wants to work on herself
Q. What evidence will you collect to determineoutcome? Check ins/ progress toward goals /how she changes relationally
R. What self of the therapist issues emerge? What do you need to pay attention to? Any blind spots? No
S. What would you like help with on this case as your peers and supervisors prepare to watch your footage? How might your colleagues be helpful? What questions do you have?