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case write

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Assignment topic: case write

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Number of pages: 5 pages / 1375 words

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CASE WRITE-UP

 

The Following Case Write-Up was developed for the Academy of Cognitive Therapy. Please see their website, www.academyofct.org for more information. The Case Write-Up is a self-explanatory conceptualization tool, designed to help therapists formulate cases. It is not designed for patient use.

 

  1. CASE HISTORY

 

  1. Identifying Information: Ms Morgan 33-year-old African-American mother of King Morgan, who has been in the care of the Illinois Department of Children and Family Services for the past six months. She lives with her paramour and her child, King. Ms Morgan has a problem of financial instability.

 

  1. Chief Complaint:

 

Ms Morgan initiated her counselling three years ago and was meeting with a therapist twice monthly at Englewood Mental Health.

Ms Morgan was diagnosed with Attention-deficit/hyperactivity disorder at the age of 6 years and depression in adolescence at the age of 11 years. The treatment options provided made her feel lethargic.

 

  1. History of Present Illness:Ms Morgan was diagnosed by hyperactivity disorder at the age of 6 and seemed to experience anger issues during her early childhood. She was later diagnosed with depression in adolescence and has struggled with low mood and anxiety since then.

The depression within was triggered by Ms Atwood’s aggression that caused Ms Morgan semi-autonomous acceleration of the stress response in 2011. Ms Morgan ended up in 15-month incarceration.

 

emotional symptoms:          low mood, anger problems anxiety         

cognitive symptoms:           avoidance of trauma, feelings of abandonment, feeling overwhelmed and incapable of parenting

 behavioral symptoms:        fear of parenting, social isolation due to feel of discrimination

physiological symptoms:        difficulty in parenting, tiredness and overprotective to children.

 

Childhood experiences defined Ms Morgans perception that she could not parent her children. Having been diagnosed with hyperactivity disorder at six years and depression in adolescence at eleven, she was placed on medication which she believed was not helping but instead made her feel lethargic.

Social unfitness was the significant stressors in Morgan’s life. She struggled to fit in her family, which discriminated her due to her sexual preferences. Ms Morgan also did not have parental care which made her feel incapable of parenting her children. Her past traumatic experiences in the foster homes further made her more traumatic depressed as he feared losing her children to the harsh fostering. Ms Morgan resorted to therapy and preferred females who have experience working with the LGBTQI population

 

  1. Psychiatric History:

 

Ms Morgan was diagnosed with Attention-deficit/hyperactivity disorder at the age of 6 years old and was prescribed Ritalin. she took the medication until she was 11 years old.

When she was eleven, she was diagnosed with depression in adolescence and was prescribed Prozac and Trazadone for her depression and anxiety. She visited the psychiatrist twice monthly for medication.

Ms Morgan lastly resorted to therapy and initiated counselling which she felt calmed her. The counselling stopped three years ago during which the physical confrontation occurred with Ms Atwood and has since been in incarceration. She now seeks parole promising that she is significantly reformed by the 15-month incarceration period

 

  1. Personal and Social History:

 

Ms Morgan identified as “African American.” And had no native American ancestry. Ms Morgan lived under foster care during her whole childhood. She did not have the motherly affection and care during the early stages. Ms Morgan had a sexual preference for both male and females that made it hard to be accepted in her family except for her father. In her adult life, she has been into many relationships and has given birth to children who were all taken away from her. Ms Morgan has had a history of violence and is lately reprimanded in 15 months’ incarceration.

 

  1. Medical History:

 

Ms Morgan has a medical history that affected her physiological functioning and treatment process. Prozac and Trazadone prescribed for her in adolescent made her feel lethargic.

 

  1. Mental Status Check:

 

The patient is fully oriented, with no other symptoms.

 

  1. DSM IV Diagnoses:

 

Axis I: Major depressive episode with trauma

 

Axis II: Self discrimination person disorder

 

Axis III: None

 

Axis IV: Unstable relationships and divorce

 

Axis V: GAF Current-65.  Best in Past Year-80

 

  1. CASE FORMULATION

 

  1. Precipitants: Ms Morgan has been through many relationships, but that did not trigger her anger issues. Finally, she found Ms Atwood, whom she thought was worthy of helping her in parenting King as she wasn’t good at parenting. Ms Atwood though had addiction in alcohol and substance abuse and sometimes would be too aggressive against King. Ms Morgans childhood experiences were triggered under these aggressive circumstances that led to physical confrontations and destruction of property in the house.

 

  1. Cross-Sectional View of Current Cognitions and Behaviors:

Ms Morgan has just involved in a physical altercation to protect young King and does not seem to notice harm she has done to the child.  Emotionally she feels protective to the child and is trying to save King from her personal childhood experiences.

Ms Morgan experiences mood fluctuations and falls into a deep depression when she thinks of Kings older siblings. The depression could be possibly due to the childhood traumas she developed while in foster care.

 

 

  1. Longitudinal View of Cognitions and Behaviors:

 

 

 

Ms Morgan grew up in a foster home but with a caring father. In her childhood, she suffered attention deficit which could have oriented her sexual preferences to whoever might have given her attention. Depression in adolescence complicated the matters. Her family discriminated ms. Morgan, on the information that she preferred both male and female relationships. Since in her childhood, she never received motherly love, Ms Morgan prefers females to males as it maybe fills some empty part in her.

 

  1. Strengths and Assets:

Ms Morgan has had significant reforms during the incarceration period and seems ready to join the society and take good care of her children. She has also shown improvement inability to provide economically for her family that’ll lead to reduced dependency.

 

  1. Working Hypothesis (Summary of Conceptualization):

Understandably, Ms morgan came to view herself as unable to parenting. Her childhood lacked parental care, and therefore she felt lonely and unloved. She claims in the interviews that her foster homes had harsh living conditions that triggered her traumatic experiences. Ms Morgan, therefore, developed a notion that as long as she wasn’t right in parenting, she had the urge to protect her children from the abuse she experienced while growing up.

 

  1. TREATMENT PLAN

 

  1. Problem List:

Depression.

Social anxiety disorder.

Post-traumatic stress disorder.

concerns with interpersonal and relational functioning

history of violence in her relationships

problems with affect regulation, including depressed mood and anxiety

history of legal involvement

 

  1. Treatment Goals:

The patient will learn to relieve depression symptoms.

The patient will learn to have stable relationships.

The patient will learn about parenting.

The patient will overcome her childhood traumas.

The patient will learn to adjust to life without using drugs and substances.

The patient will learn how to build healthy communication skills.

Objectives.

To attend therapy sessions with the goal of temper control.

To take medication to relieve depression.

To attend a meeting to help with good communication skills.

To attend counselling sessions with a spouse to have stable relationships.

To report for all sessions with the children officer to check progress in parenting.

  1. Plan for Treatment:

 

Patient information. The counsellor will get to gather personal information about the patient. This will include name, date of the plan, social security number and insurance details.

Proceed to diagnostics. The counsellor will conduct diagnostics on the patient’s history and current condition. This section will take into account the medications provided, their merits and demerits. The duration of diagnosis will be recorded. Ms Morgans childhood traumas and depression will be considered alongside her self-initiation of counselling as a remedy.

Problems and goals. The counsellor will proceed to identify the issues present, dreams and the objectives to achieve those goals. The above points, objectives and goals will apply for Ms Morgan.

Consensus. The counsellor and the patient will sign on the treatment plan to prove that both were involved in the conception.

 

  1. COURSE OF TREATMENT
  1. Therapeutic Relationship:

Ms Morgan has been involved in therapeutic relationships before. This kind of therapy needs the development of trust and sense of security between the counsellor and the patient. Ms Morgan should be afforded with service providers who are not only culturally competent but have experience working with the LGBTQI population. The provider should be preferably female to avoid interference with her childhood traumas.

 

  1. Interventions/Procedures:

 

Ms Morgan is to be placed on a compulsory twice a month counselling session.

Prescription of medicine in case of anxiety attacks and extreme depression.

 

 

  1. Obstacles:

 

Ms Morgan forms part of the LGBTQI population and finding a perfectly suitable counsellor is problematic given that most of the community is heterosexist.

Ms Morgan has extreme reactions to depression medication that makes her feel lethargic hence reduces the chances of their application.

Ms Morgan has a small child that deserves motherly caring hence need to expose her to childhood trauma.

 

  1. Outcome:

 

Ms Morgan responded positively to therapeutic counselling and had good progress with temper management, depression management and development of socio communication skills. She was ready to resume her economic empowerment programs and caring for her baby, King.

Ms Morgan had problems with coping to medication as there were adverse side effects on her.

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