I. Identifying Information
The client is a 25 year-old female with one or more children. Her racial and ethnic information is unknown. Marital status is also unknown, but she is reported to be with a boyfriend.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
II. Reason for Referral
The client was referred for evaluation and treatment recommendations. The client was initially referred by the Department of Social Services and she underwent psychological evaluation in order to assess her current level of functioning, specifically to examine whether she suffers from any psychological disturbance that may interfere her capacity to effectively parent.
III. Current Situation and Functioning
The client has been struggling with a number of difficulties including financial and housing. She, along with her boyfriend, is unemployed and homeless. It should be noted that she is in the process of trying to obtain disability benefit.
IV. Relevant History
The client reported having a history of significant trauma (physical and sexual abuse) beginning in early childhood. This resulted in multiple PTSD symptoms including “intrusive recollections and flashbacks, a wide array of avoidance behavior, and extreme hyper arousal”. It is also reported that she exhibits “cognitive, behavior, emotional, and neuro-vegetative symptoms of major depressive disorder” as well as “history of auditory hallucinations” throughout her life.
As for the past diagnosis and treatment history, she has been in psychiatric treatment for several years and has been on psychotropic medications, including atypical antipsychotics, and SSRI’s, and has had diagnosis of depression, anxiety, borderline personality disorder as well as schizophrenia.
V. Behavioral Observations
The client’s hygiene and grooming appeared “below average”. Also, she was clearly anxious (i.e. fidgety, hands wrung, sitting on the edge of her seat, reported tightness in chest, and increased reparation rate as well as near panic attack feeling)
Client’s showed “below average motivation” and was “distracted and preoccupied”. It was also suggested that she has difficulties with language processing skills (This raises questions regarding how accurately the test scores reflect the client’s cognition).
Overall, the client’s stories contained a theme of isolation and alienation as well as feelings of inferiority and even abandonment. Her story of the boy who “taught himself” and the man with a “hump on his back whom people laughed at” as well as the dead woman who was “left” there suggest such theme. Also, the theme of betrayal and distrust is prevalent through the characters she created such as the woman in the picture 3GF, picture 4, and picture 13MF. It is clear that the client views her environment as a rejecting unfriendly and not trustworthy world. Accordingly, she views herself as being unaccepted and disconnected. The main defense against her fear and axiety toward such environment is her tendency to avoid. Ironically, her main needs and drives are revealed as affection and dependency.
VI. Case Conceptualization
Several issues in the process of conceptualizing the client and her problems need further investigation and clarification. For example, the mood dysregulation mentioned in the narrative needs to be evaluated further since it can be a symptom of a borderline personality disorder or a part of mood disorder. It can also be a symptom associated with the past trauma. Another example is the reported history of perceptual disturbances. It is unclear whether if it is symptomatic of PTSD or of schizophrenia. Regardless, her psychological capacity to effectively parent her child(ren) is questionable at this present time. Her description of Picture 7GF of TAT could be a snapshot providing a window into her emotional resources (or lack thereof) as a parent.
I. Identifying Information5
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