Cheat Sheet
- Psychological Treatment Case
- Patient’s Demographic Information
- Confidentiality, Limits of Informed Consent
- Identification and Referral
- K.T. was referred by her teacher. Abuse report was initiated and processed by the practicum trainee
- Reason for referral: patient’s consecutive absences at school and possible signs of child abuse, depression, among other possible psychological conditions
- Relevant Background Information
- Patient lives with her mother, step father, two younger siblings in a small 2-bedroom apartment
- Reportedly financially stable
- K.T. despises her mother and step-father; has only one support system-her brother.
- K.T. experienced being abused by her grandfather, mother (physically).
- K.T. has been involved in a juvenile justice case when she beat up a girl, suggesting that she only beat the girl up to defend herself as the girl was the first one who attacked her.
- Consumes Marijuana at least two times a week
- Has a history of suicide—drinking blue pills
- Primary Issue for Success
- Inability to wake up in the morning and sleep well at night
- Secondary Issue for Success
- Patient’s unhealthy and unstable relationship with her family
- Strengths and Weaknesses
- (+) Strong support system—her brother
- Unhealthy and unstable relationship with her family
- Barriers
- Past traumatic experiences
- Diagnoses
- PTSD
- MDD
- Parent-Child Relational Problem
- Treatments
- Cognitive Behavior Therapy
- Goal I: To Build Healthy Social Relationships through proper communication
- Goal II: Reduces client’s sense of loneliness as a result of the inability to communicate with her parents and peers.
PSYCHOLOGICAL TREATMENT CASE
CHRONOLOGICAL AGE: 15
GENDER: Female
CIVIL STATUS: Single
MEDICAL RECORD NUMBER: N/A
REFERRAL SOURCE: Dr. S
EXAMINER: Practicum Trainee
CONFIDENTIALITY/LIMITS OF INFORMED CONSENT
This report contains sensitive information from a patient. No letter that waives the patient’s right to confidentiality has been provided. Disclosure of any material provided herein without the permission of the court, the patient, or the patient’s parents or guardian, or any third party provider (i.e. medical insurance service provider), is prohibited unless otherwise permitted in accordance with the Welfare and Institution Code Section 5328.
IDENTIFICATION AND REFERRAL
This is a case of K.T., a 15-year-old (DOB: 7/27/98) Latina female student. The patient was initially referred to therapy for truancy by her teacher mainly due to the latter’s concern about the patient’s current level of emotional stability. One instance that the teacher who referred the patient reported was when K.T. wrote in a classroom activity about her problematic relationship with her brother and other members of their family.
Upon conducting an interview-based assessment, the patient showed signs of symptoms of anxiety such as profuse sweating, subjective feelings of having low energy, loss of drive to go out with family and friends, and basically any other type of social gathering. The patient also reported of recurrent episodes of unintentionally relieving a traumatic experience she encountered when she was 3 years old. In that experience, a person was murdered in front of her. As a result of all the emotional stressors, and the past traumatic experience she has been exposed to that she mentioned, she reported of having had numerous suicidal thoughts and a single attempt when she was seven.
The patient also reported that she has been a victim of abuse by her grandfather when she was seven for at least a year and a half. Eventually, the patient’s mother found out about the abuse and immediately reported the grandfather to the police authorities which led to his arrest. The patient reported that being a victim of abuse for about a year and a half scarred her emotionally to the point that there are episodes wherein she constantly sees virtual reenactments of the abuse especially when hearing subjects and conversations that are about or at least somehow closely related to it. There were even instances wherein the patient completely blacked out after remembering one instance of the abuse she suffered from her grandfather.
The mother, who was the one who reported the grandfather who abused the patient to the authorities, was also reported to be an abuser. K.T. reported that she was hit numerous times by her mother especially whenever she makes mistakes at home or at school.
According to the California Legislature, a student missing more than 30 minutes of instruction without an excuse during the entire school year must be classified as truant and must be reported to proper school authorities.
K.T. falls in the category of chronic Truant. Effective January 1, 2011, EC Section 48263.6: Any pupil subject to compulsory full time education or to compulsory continuation education who is absent from school without a valid excuse for ten percent or more than the minimum threshold of absences permitted by the school based on the total number of school days in one school year, from the date of enrollment to the current date, is deemed a chronic truant, provided that the appropriate school district officer or employee has complied with EC sections 48260, 48260.5, 48261, 48262, 48263, and 48291.
RELEVANT BACKGROUND INFORMATION:
Current Living Situation
Patient lives with her mother, her step father, and two younger siblings in a small two-bedroom apartment. Her mother and her step father currently acts as her and her siblings’ guardian. She also reported that when it comes to financial and other related capabilities, their guardians are more than capable to provide for their needs and other aspects of care such as home and other types of expenses,
Family Background
Patient reported that she does not like her mom and that she despises her step father due to the following reasons; that her mom is weird; that she thinks she has a bipolar disorder. K.T. also reported that the only person in the entire family she feels comfortable with is her brother and that she is actually deeply attached to him to the point that she cannot live without him because he is the only existing support system that she has. K.T.’s mom got divorced from her real and biological father when she was seven years old and after the finalization of the documentation of the divorce, she and her mother have not heard from him ever. When asked about her feelings, perceptions, or attitudes about the fact that she does not live with her real father, she said that it did not really matter to her because if her father wanted to be with her and her mother, he would be right next to them to support them.
All of these factors and events led to the filing of a child abuse report. Basically, the rationales behind the filing of the report are as follows: due to the observation of the client’s behaviors during 3 consecutive school days, the gathered information regarding client’s relationship with her mother and other significant members of her family, among others. Client was observed wearing the same outfit to school for three days in a row, with stains, unlike her previous behavior of wearing different outfits to school on a daily basis, appropriately put together. The patient also, on numerous occasions, reported that their mother beats them up to the point that social workers visited their home one time to check on their status after the neighbors reported the mother’s allegedly abusive behavior.
Medical and Developmental History
No pertinent findings
Juvenile Justice Involvement
Patient has a history of being involved in a juvenile offense. She once got arrested after fighting back at some girl who hit her when she was out with her boyfriend by beating her up leading to moderate to severe injuries of the girl. K.T. stayed inside a juvenile hall for a couple of days. The case was filed more than a year ago in which she also went under one year probation.
Psychiatric History and Hospitalization(s)
Substance Use
BEHAVIORAL OBSERVATIONS
Primary Issue for Success
The main issue that the patient may consciously or unconsciously have that may hinder success would be her inability and lack of energy to wake up in the morning and sleep well at night. This prevents her from punctually attending school. Client’s loss of interest and drive to participate in school activities may also be a significant factor.
Secondary Issue for Success
The client’s relationship with her family members prevents her from fully enjoying her life both at home and at school. At some point, it may even be theorized that she brings her painful experience at home in school—something which negatively affects her school performance.
STRENGTHS AND WEAKNESSES
The client has a strong support system. According to her reports, the only support system that she has is her brother. She stated that her brother is the only reason why she wants to live and why she wants to succeed in life—she wants to make him proud and happy. The client has a healthy understanding of past traumatic experiences and how it has contributed to her present behaviors. Client does not cope well with daily stressors such as the ones she often encounter at home and at school.
BARRIERS
DISCUSSION OF THE DIAGNOSIS
My diagnostic impressions are based on the DSM 5 criteria.
Post-Traumatic Stress Disorder (PTSD): Client reported experiencing a traumatic event in the past. For one, she reported to have seen an incident wherein a person got murdered right in front of him. She also has had two recorded suicidal attempts. Apart from these two, she also presents with clinical signs and symptoms of PTSD such as intense fear, horror, and feeling of helplessness, coupled with virtual reoccurrence of the traumatic events that she encountered. When asked how frequent she experiences these manifestations, she said she experience them at least twice a week.
Major Depressive Disorder (MDD): The client may also be diagnosed with MDD due to the manifestation of a constant depressed mood that she started to experience when she got abused by her grandfather; and her recurring suicidal attempts and recurring suicidal ideation.
Parent-Child Relational Problem: Client reported having a volatile relationship with her family members, especially with her mother and step-father. Client also has a problematic relationship with her boyfriend and with her stepfather because of her fear of men due to her past experiences of being sexually abused.
TREATMENT ORIENTATION
Cognitive Behavioral Therapy (CBT): Dysfunctional thinking, which influences the patient’s mood and behavior, is a common intervention in treating a wide range of psychological disturbances. When people learn to evaluate their thinking in a more realistic and adaptive way, they experience improvements in their behavior. Cognitive Behavioral Therapy (CBT) is used to improve mood and behavior, basic beliefs about themselves, their world, and other people. Modifications of their underlying dysfunctional beliefs produce more enduring change. For example, my client continuously blames herself for being sexually abused in the past and she believes that her life is over and that she is not going to be well again. Also, every time she talks about her mistakes, she often adds that she is not good at correction them. These are all indicators of cognitive distortions.
CRIMINOGENIC GOAL #1: Building healthy social relationships through proper communication
- Begin to make good eye contact with people, and start responding appropriately.
- Reinforce client’s eye contact and proper communication
- Role play with client social situations
- Increase interest in communicating with others.
Time Frame: One month to one year. Patient will be treated one on one for at least once a week.
Measure: Journaling the process. Noting significant and remarkable regression and progressions in her ability to communicate with other people, and also documenting how she uses the learned skill in her daily activities.
CRIMINOLOGIC GOAL #2: Reduces client’s sense of loneliness as a result of the inability to communicate with her parents and peers.
A. Outcome Goal #1 should assist in Outcome Goal #2
B. Build and maintain therapeutic rapport with client
1. Provide supportive therapy to help client feel understood.
2. Explore client’s emotional responses to her mother’s behaviors.
3. Demonstrate acceptance to the client through validation and active listening.
C. Increase client’s coping strategies.
1. Identify client’s current coping strategies.
2. Reinforce client’s report of current strategy (currently reported as being her brother)
3. Reinforce client to develop hobbies and interests in things that will help her cope with stress.
Time Frame: 2 months to a year, one on one individual therapy once a week
Measure: Track client’s progress on making new friends and developing new hobbies.
Monitor client’s report of attempts to make new friends and activity involvement to gain interest in them.
DSM V - DIAGNOSIS:
309.81 Post Traumatic Stress Disorder
296.33 Major Depressive Disorder
V61.10 Parent-Child Relational Problem
RECOMMENDATIONS
1) Client would benefit from a thorough psychological assessment and ongoing psychotherapy treatment.
2) Self Management Time: Client would benefit from setting aside a few minutes each week to check on her mood and to use learned skills in order to problem solve situations or feelings that may be negatively affecting her mood. It is beneficial; because it can be conducted anywhere and anytime it is convenient for the patient.
3) Client would also benefit from family therapy, if agreed by her mother.
Should you have any further questions regarding this report or any other related matter, please do not hesitate to contact me. Thank you for the opportunity to evaluate this client.
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References
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: Author.
Beck S. D. (2011). Cognitive Behavioral Therapy: Basics and Beyond. New York: Guilford Press.
CAL PENAL Code § 11164
Welfare and Institution Code § 5328
