Couc693week

Couc693week

client information
Demographic Information

• Female client
• Middle adulthood
• 49 years old
• Lives alone
• Divorced/Single
• Mother of adult daughter
• Employed in multiple part-time positions
• Currently attending school

Bio-Psycho-Social-Spiritual History

Biological

• Reports diagnosis/history of OCD
• Increased OCD symptoms during periods of stress
• Reports anxiety symptoms

Psychological

• Long history of anxiety
• Overthinking and excessive worry
• Difficulty tolerating uncertainty
• Uses isolation as a coping mechanism when overwhelmed

Social

• Works three jobs
• Limited downtime
• Daughter graduating and preparing to move in
• Concerned about finances and housing
• Reports feeling overwhelmed by social interactions

Spiritual

• Reports strong faith in God
• Believes God guided decision to return to school
• Uses faith as a source of strength and motivation

Presenting Concerns/Problems

• Increased anxiety
• OCD symptoms worsening
• Financial stress
• Housing concerns
• Daughter moving in after graduation
• Difficulty managing multiple responsibilities
• Fear of uncertainty and lack of control
• Excessive worry
• Overthinking
• Financial stress
• Daughter moving in after graduation
• Increased OCD symptoms
• Anxiety related to uncertainty
• Limited time for self-care
• Feeling overwhelmed by multiple responsibilities

Diagnosis

Primary Diagnosis

• Generalized Anxiety Disorder (F41.1)

Secondary Diagnosis

• Obsessive-Compulsive Disorder (F42)

Diagnostic Rationale

• Excessive anxiety and worry across multiple life domains
• Difficulty controlling worry
• Persistent overthinking
• Anxiety related to finances, housing, work, school, and family responsibilities
• Long-standing history of anxiety symptoms
• OCD symptoms worsen during periods of increased stress
• Reports obsessive thoughts and compulsive behaviors such as increased cleaning and washing

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Slide 3

Theoretical Orientation

Person-Centered Therapy

• Empathy
• Active listening
• Unconditional positive regard
• Reflection of feelings
• Reflection of meaning
• Therapeutic relationship

Cognitive Behavioral Therapy (CBT)

• Identify cognitive distortions
• Challenge irrational thoughts
• Reduce catastrophic thinking
• Increase emotional awareness
• Improve coping skills
• Strengthen emotional regulation

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Treatment Plan

Goal 1: Reduce Symptoms of Anxiety

Objective

• Client will identify three triggers contributing to anxiety and excessive worry.

Intervention

• Utilize CBT techniques to identify cognitive distortions and challenge irrational thoughts.

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Goal 2: Improve Coping Skills for Stress Management

Objective

• Client will demonstrate three healthy coping strategies to manage anxiety between sessions.

Intervention

• Provide psychoeducation regarding mindfulness, grounding skills, relaxation techniques, and deep breathing exercises.

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Goal 3: Reduce OCD Symptoms and Compulsive Behaviors

Objective

• Client will identify three situations that trigger obsessive thoughts and compulsive behaviors.

Intervention

• Utilize CBT interventions to increase awareness of obsessive thinking patterns and reduce compulsive responses.

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Goal 4: Increase Tolerance for Uncertainty

Objective

• Client will identify two healthy ways to cope with situations outside of her control.

Intervention

• Explore fears related to uncertainty and restructure catastrophic thoughts through CBT interventions.

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Goal 5: Increase Self-Care and Emotional Balance

Objective

• Client will engage in two self-care activities per week.

Intervention

• Assist client in developing a self-care plan that includes personal downtime, stress reduction activities, and healthy boundaries.

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Slide 4

Ethical Considerations

• Confidentiality
• Informed consent
• Professional boundaries
• Client autonomy
• Beneficence
• Nonmaleficence
• Scope of competence
• Monitoring counselor bias
• Ethical management of anxiety and OCD symptoms

Multicultural Components

• Spiritual beliefs as a source of resilience
• Financial stress impacting mental health
• Educational and career transitions
• Family role as a mother
• Individual values regarding independence
• Cultural views regarding responsibility and family obligations
• Respect for client worldview and lived experiences