MCC 670 – Case Formulation

MCC 670 – Psychodynamic Models

Psychodynamic model hypotheses are based on the work of Freud, Jung, & Adler. They focus on unconscious mechanisms and early childhood experiences.

internal parts (p1)

overview & key concepts

“The problem can be explained in terms of Internal Parts that need to be understood, accepted or modified and coordinated.” (Ingram, 2912, p. 289) In other words, there exists a lack of awareness of how subconscious thought processes and/or childhood experiences create conflict in our lives. Treatment centers around resolving this inner conflict and addressing this resistance. Ingram, (2012), discussed concepts within transactional analysis as highly relevant here.

when is hypothesis a good match

“you can only work productively using this hypothesis when the client can reflect on different parts as aspects of one’s personality, and be able to take a playful, ‘as if’ attitude when speaking with the voice of an inner part. This requires the maturity to take a metacognitive perspective.” (Ingram, 2012, p292)

treatment planning ideas

Treatment planning involves the resolution of our missing pieces as areas of conflict. In DBT, the outcome of this would be wise mindedness. In transactional analysis it would be an identification if inner parts and resolution of inner conflict.

example #1: overcome stuckness

“Resistance is often explained as a battle between inner parts: one part wants to change, while the other does not – out of fear of the risks or enjoyment of the benefits of staying the same (secondary gains)”. (Ingram, 2012 p234).

example #2: gestalt 2-chair technique

Therapist guides client to talk back and fort between two parts, each spatially linked to a different chair. The therapist’s role is to clarify. (Ingram, 2012, p296).

recurrent parts (P 2)

overview & key concepts

“A Recurrent Pattern, possibly from early childhood, is causing pain and preventing satisfaction of adult needs…Insights may not be enough, the client may need to experience and learn to tolerate painful emotions.” (Ingram, 2013, p301). We generally tend to utilize the most effective solutions based on past experience. Ingram, (2012), discusses attachment theory and family of origin here.

treatment planning

“you need to be specific about what exactly is being reenacted and offer your hypothesis about how, specifically, the pattern occurs in current functioning.” (Ingram, 2012, p305)
Avoid blaming and focus on promoting insight and provide validation. Be aware of countertransference.

deficiencies in self & relational capacities (P3)

overview

“The client demonstrates Deficits in Self and Relational Capacities and seems to be functioning at the maturity level of a young child.” (Ingram, 2012, p. 312). Ingram, (2012), goes into great detail on various theories that discuss stages of childhood development.

treatment planning

Ingram, (2012) suggests holding off until you can understand their developmental level relationally. Psychoanalytic strategies can might involve a therapist being as a “selfobject [for purposes of] learning vicariously” (Ingram, 2012, p302). Humanistic theories can address these issues by enabling client’s to be less reliant on approval from others.

unconscious dynamics (p4)

“client suffers from irrational, self-defeating behaviors or distressing symptoms that do not respond to ordinary interventions. These may stem from unconscious conflict or self-protective responses to traumatic events. Defense mechanisms function to keep the conflict unpleasant affects out of awareness” (Ingram, 2012, p.325). This hypothesis utilizes some Freudian concepts that I’m not a fan of.

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MCC 670 – Cognitive Models

“Cognitive hypotheses can be applied with every client because the content and process of thought is an element in all problems and solutions” (Ingram, 2012, p. 191). This hypothesis is based on psychodynamic, humanistic, existential, and CBT models.

Metacognitive Model (C1)

Metacognition refers to thinking about thinking. In other words, you are focusing on your thoughts and feelings without identifying or reacting to them. Critical thinking is the ability to evaluate thinking and requires the following skills:

  1. Able to separate self from thoughts
  2. Not give power or control to thoughts
  3. Evaluate one’s thinking in terms of goals
  4. Taking the role of executive over one’s thoughts.
  5. Non reactivity to inner experience

is this hypothesis a match?

This hypothesis is useful in achieving emotional regulation, achieving goals, & harmonious relationships. It is useful for OCC, PTSD, depression or substance use.

treatment planning

Step one involves psychoeducation of the fundamental nature of metacognitive beliefs. Homework assignments that allow us to apply this skill and engage in self-monitoring of our thoughts. Ingram, (2012) also mentions clarifying questions as useful to understand her thinking. Ongoing efforts to build metacognitive skills and practice mindfulness & acceptance activities are also discussed by Ingram, (2012).

Limitations of Cognitive Map (C2)

overview

This hypothesis is useful when a “person’s cognitive map (e.g. beliefs, schemas and narratives) are causing problems or preventing solutions” (Ingram, 2012). Maladaptive belief systems act like “self-fulfilling prophecies that need to be identified, evaluated, and challenge” (Ingram. 2012).

key concepts

cognitive map

“deep structures of thinking, such as schemas, rules, or cultural worldviews. They provide meaning and purpose, a rulebook for how to behave the world” (Ingram, 2011, p. 195).

limiting narratives

“a cognitive map that is extended through time” (Ingram. 2012, p. 292). We all tend to arrange life experiences sequentially and create story around these experiences for sense of continuity and meaning. We can address them by understanding simply that our stories define our life.

lifestyle

“Adler used the term lifestyle for “the convictions individuals develop early in life to help them organize experience, to understand it, to predict it, and to control it” (Ingram, 2012, p. 198).

ABC Model

[A] Event -> [B] Thinking -> [C] Feelings
[A] Event -> [B] Causes -> [C] Feelings

Deficiencies of cognitive processing (C3)

overview & key concepts

“the client demonstrates Deficiencies in Cognitive Processing, poor reality testing, and an inflexible cognitive style” (Ingram, 2012) This hypothesis is useful with depression, anxiety disorders, or psychosis, as an example.

information processing

Ingram, (2012), discusses information processing and describes concepts of input, processing, and output. Input consists of how we intake information. (i.e. Attentional mechanisms). Processing consists of how we imbue this data with meaning (i.e. Perception). Output consists of our behavioral response.

Beck’s Errors in Thinking

  1. Overgeneralization – (always or never)
  2. Personalization (assumption that external events r/t you)
  3. All-or-Nothing Thinking – Polarizing thoughts black/white
  4. Arbitrary inference – Jumping to conclusion.
  5. Mind Reading – Assuming you know what others are thinking
  6. Emotional Reasoning – thinking with feeling

blocks to listening

Ingram, (2012), discusses filtering, dreaming, prejudging, and rehearsing and identifying. The MBTI describes cognitive styles & the MMPI describes defensive styles.

treatment planning

Ingram, (2012), discusses the concepts of Socratic dialogue, collaborative empiricism, confrontation, CBT, and homework assignments….

Dysfunctional self-talk (C4)

overview & key concepts

DYSFUNCTIONAL SELF-TALK (C4) – The problem is triggered and/or maintained by Dysfunctional Self-Talk, (i.e. automatic thoughts, internal tapes, or interior monologue). Sample problem areas can include anxiety, depression, impulsive behavior, healthy eating, substance abuse (Ingram, 2012).

treatment planning

It starts with promoting self awareness and gaining an understanding of our thoughts and belief systems. Deciding to change and enacting a plan to make it happen are final steps.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment ​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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Mcc670 behavior & learning models

Overview of Hypotheses

“The Hypotheses in this chapter apply models of learning from experimental and social psychology: operant conditioning, respondent conditioning and social learning theory.” (Ingram, 2012). I’ve reviewed these elsewhere for the NCE exam.

Antecedents & Consequences (BL1)

Overview & Key Concepts

The treatment plan should be based on an analysis of Antecedents (triggers) and Consequences (reward and punishment). “Interventions based on functional analysis of behavior. Strategies of behavioral change based on studies from operant conditioning” (Ingram, 2012, p. 158). B.F Skinner’s theory stated behavior is a function of its consequence. Triggers are stimuli that causes behavior to happen. Positive and negative reinforcement allow us to control behavior. Applied behavioral analysis allows us to gather data based on these concepts and design interventions accordingly. Useful with children (i.e. Autistic child with disruptive mood disorder)

Step #1: Define Problem Behavior

What are the problem behaviors? Is it related to a skill deficit or trigger? Can you clarify the behavior in a clear and measurable fashion?

Step #2: Identify Antecedents

What stimulus occurs before the specific behavior? It can be a biological condition, emotional state, or cognitive trigger.

Step #3: Identify Consequences

What sort of rewards and/or punishments serve to explain why the individual engages in the specific behavior? How is behavior reinforced?

Step #4: Examine Sociocultural environment

What cultural norms exist and how would you characterize the client’s support system. In what way do these factors also play a role in the client’s behaviors.

Step #5: conduct a cost/benefit analysis

This involves examining how the above factors weigh in the client’s decisions to behave? Clarify the weight and sequence of these factors play in the overall decisional equation. Ingram, (2012) defined functional analysis as an “analysis of specific contingencies that maintain problem behaviors along with an analysis of the necessary contingencies for the desired behavior to replace the problem behavior.” (Ingram, 2012). The payoff can be a means of escape from something negative. Or it can provide a tangible reward (i.e. Sensory and/or attention-getting benefit). These steps allow us to develop a treatment plan.

The Treatment Plan

The goals of this hypothesis are fairly straightforward and involve either increasing desired behaviors or decreasing undesirable behaviors. Homework assignments between sessions are useful alongside the gathering of data that the client can examine to clearly see the benefits of all interventions. Ingram, (2012) also discusses common strategies such as +/- reinforcement, contingency contract, etc. Finally, if the client remains noncompliance, it may be useful to utilize another hypothesis (p4 or p1).

Conditioned Emotional Responses BL2

Overview & Key Concepts

This hypothesis is based on Pavlov’s theory and concepts such as conditioned/unconditioned responses or extinction. Conditioned Emotional Responses are often at the core of extreme distressful responses or maladaptive behaviors. “There is an intense emotional response that is not justified by the stimuli in the current environment, along with a lack of cognitive mediation, we can infer that prior learning involved classical conditioning” (Ingram, 2012, p. 172).

is this a good match

“There are many situations where extreme emotional reactions are justified, as with traumatic events (discussed under C2), deaths and other losses (C4), and social injustice (SCES). Similarly, intense emotional reactions accompany developmental transitions (CS3), loneliness and social isolation (SCE3), and changes in one’s social environment and required social role (SCE4)” (Ingram, 2012, p. 173)

Treatment Planning

Usually involves some form of systematic desensitization of anxiety-producing situations where the trigger is paired with relaxation responses. However, beforehand this should first include some relaxation training. Followed by the development of a fear hierarchy from lowest to highest. This can then allow the therapist to utilize a gradual exposure plan.

Skill Deficits (BL3)

Overview & Key Concepts

This hypothesis is useful if skill deficits exist and the client requires to gain competency in a particular area. The treatment goals tend to center around providing opportunities for learning. Sample problem areas can include anger management or social skills. This hypothesis is based on Bandue’s conditioning principals which state that we learn by observing and mimicking others.

treatment planning

“It may be helpful to orient the client to the ‘learner role’, which requires an acceptance that achievement of proficiency requires effort, practice, and acceptance of mistakes” (Ingram, 2012). The first step involves the evaluation of the client’s skill level. This requires an identification and clarification of the problem then brainstorming solutions. Graduated tasks and homework are essential with the utilization of a step-by-step plan. Behavioral rehearsal is an essential component of this process. Ingram, (2012), suggests that interpersonal therapy or DBT.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment ​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Sociocultural & Environmental Factors

CHAPTER 14 “Social, Cultural & Environment Factors” in Ingram, (2012) discusses his hypotheses that look outside of the individual for explanations and solutions.  Draws from systems theory and varied disciplines. The table below comes from (Ingram, 2012, p, 285).

This post is part of an excruciatingly frustrating list of posts where I take old notes from a class. In order to expedite matters, I’m doing the cliff notes version. Above, is key info on the hypotheses. Below, are examples of these hypotheses applied to my own life…

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Existential & Spiritual Models

“By applying the hypotheses in this category, the therapist refuses to pathologize, medicalize, or objectify the patient. Clients do not have a ‘disorder’ but are struggling with inevitable problems of human existence….The personhood of the therapist and the egalitarian, genuine quality of the therapeutic relationship may be more important than other therapeutic ingredients.” (Ingram, 2012, p, 257).

This post is part of an excruciatingly frustrating list of posts where I take old notes from a class. In order to expedite matters, I’m doing the cliff notes version. Above, is key info on the hypotheses. Below, are examples of these hypotheses applied to my own life…

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

 

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MCC 670 – Body & Emotions

Body & Emotion Hypotheses

These hypotheses are based on the idea that the body and mind are interconnected as two integral components of our overall well-being. “There are physiological causes for mental symptoms, psychological causes for physiological changes and psychological and biological factors that co-vary without our understanding the direction of causation.” (Ingram, 2012).  For example, anxiety can be a byproduct of a thyroid condition, or it can be a part of life stressors where the body/mind connection is at play.  This section talks about two hypotheses…

Biological Cause (BE1)

Overview and Key Concepts

“A wide range of physiological conditions can produce psychological symptoms. Psychosocial assistance is needed with coping with these issues” (Ingram, 2012). Examples of this might be strokes, brain tumors Alzheimer’s, fetal alcohol syndrome, endocrine disorders, vitamin deficiency, AIDS.  What follows is a listing of key ideas to keep in mind:

  1. Does the individual have a medical diagnosis.  Need to contact physician for purposes of care oordination.  
  2. Is there a medical emergency that can cause death, serious injury, or disability?
  3. Are there medically unexplained symptoms? (Somatization disorder?)
  4. is there a co-occurring medical illness and mental disorder 

Is this hypothesis a good fit?

Examples of problems that fit a biological cause hypothesis:

  1. Inadequate self-care
  2. Difficulties coping with health problem
  3. Compassion fatigue.
  4. Problem associated with terminal illness 
  5. Problems associated with drug addiction 

When should a therapist refer their case to a medical professional?

  1. “A need for medical referral is recognized by such data as impaired memory, concentration, consciousness, changes in appetite, weight, sleep patterns, mood and personality traits” (Ingram, 2012).
  2. “Events that require referral: poor grooming, neglect, loss of competence, delirium, dementia, amnesia, stroke, head trauma” (Ingram, 2012). 
  3. Finally, it is important to be aware of the fact that medical problems can masquerade as mental health issues

Finally, Ingram (2012), discussed two issues in detail that are an ideal fit for this hypothesis:  substance abuse and adapting to disability.

substance abuse.

An MSE, biopsychosocial assessment and CD eval are all essential.  Should assess history, quantity and frequency of consumption.  Also need to understand how addiction has affected life/relationships.  Keep in mind, the biological components:

  1. Intoxication: produces changes and impairments in client’s mental status.
  2. Dependence is a physiological and psychological  issue
  3. Affects of an addictive substance can mimic psychological disorders 

Coping with disability

Biological conditions can “affect an individual’s emotional, biological, spiritual and cognitive well-being” (Ingram, 2912).  How does this issue overwhelm an individual’s ability to cope? Acceptance, understanding and self-education are useful in learning to cope with irreversible medical issues.  Examining opportunities for prevention and healing require individuals to closely examine their lifestyle.

Treatment Planning

Assess the client’s understanding of the nature of their condition and prognosis.  Education and radical acceptance may be in order

  1. Do not forget ethical issues (I.e mandatory reporting laws) & remain within scope of care, utilizing referrals where necessary.
  2. Help client work through a system of self management that includes addressing ADL’s and making adaptations as needed.  
  3. Provide time for the client to work through psychological and relational and issues.
  4. It will be essential to function as part of an interdisciplinary team to coordinate care.  
  5. be aware of family involvement in treatment discussions.

with terminally ill clients:

  1. hospice or palliative care?
  2. Kubler-Ross stages
  3. spiritual & existential issues
  4. EOL decisions 
  5. assess/address quality of life.

Alcohol and Drug Treatment

Initial Phase requires detoxification under medical supervision.  Residential programs are the next phase.  Then client’s enter outpatient treatment and participate in 12-step programs

Finally, Ingram (2012) lists the following hypotheses as useful alongside this one:
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  • Limitations of Cognitive Map (C2) 
  • Antecedents and Consequences (BL1) 
  • Conditioned Emotional Responses (BL2)
  • Loss  and Breavement (CS4)
  • Spiritual Dimension (ES3) 

Medical Interventions (BE2)

Overview and Key Concepts

“The primary application of this hypothesis will be when the use of psychotropic medication is indicated for a psychiatric disorder” (Ingram, 2012, p. 78).  For example, someone has a gastric-bypass and needs help adhering to new diet and coping with lifestyle changes.  Ingram, (2012), caution against giving medical advice and stay with scope of practice.  What follows is a list of sample treatment considerations:

  1. Referral & coordination of care
  2. promote adherence with doctor’s recommendations 
  3. CBT (i.e. Cost-beneft analysis).
  4. Know basic psychopharmacology

Is this Hypothesis a good fit?

“…for severe disorders, such as Schizophrenia and Mania, psychopharmacological treatment is not considered optional, but is rather a part of the ‘standards of care'” (Ingram, 2012, p. 80). Referrals and care coordination are essential in such cases.  Ingram lists the following as reasons for seeking psychiatric referral:

  1. “symptoms are interfering with basic ADL’s
  2. The client is a suicide risk
  3. diagnosis exists which needs medication.
  4. The symptoms persist with medications.
  5. The client is self-medicating
  6. Psychotropic medication worked in the past.

Treatment Planning Ideas

The basics of treatment are discussion, psycho-education, assistance with decision-making, referral, and coordination of care with a medical practitioner.

DISCUSSING PSYCHOTROPIC MEDICATION:

  1. What are Side-effects r/t medications
  2. Reasons for non-compliance (why?)
  3. Problems emerging after symptom management increases.  (I.e. Suicide risk, ADL issues, & interpersonal problems).

Mind-Body Connections (BE3)

Overview and Key Concepts

“A holistic understanding of Mind-Body Connections leads to treatment for psychological problems that focus on the body and treatment for physical problems that focus on the mind. This hypothesis is a good fit for clients classified as somatizers, for many types of stress and tension complaints, and for sexual disorders. Clients often need to increase their awareness of and control over their bodies and to develop a somatic awareness of feeling” (Ingram, 20-2, p. 88).

  1. Healing mind also heals the mind
  2. Improvements in physical help improve psychological function.
  3. Stress is a mind-body issue.  

How you determine fit?

  1. “Stress and anxiety tension reduction 
  2. Problems with eating, sleeping and sexual function
  3. Medical complaints
  4. Chronic pain
  5. Body image problems
  6. Performance problems
  7. Restricted and rigid personality styles” (Ingram, 2912).

Treatment Planning Ideas

  1. SUD scale & mind/body awareness
  2. Relaxation and stress management
  3. methods that stress mind/body connection.

Emotional Focus (BE4)

Overview and Key Concepts

This hypothesis focuses on helping the “client improve awareness, acceptance, understanding, expression and regulation of feelings” (Ingram, 2012).  Key concepts

Emotions Defined:

“complex set of interactions mediated by neurons and hormones giving rise to affective experiences that generate cognitive processes, activate physiological adjustments, and lead to behaviors not always adaptive.” (Ingram, 2012).

Emotional Reactivity

how much affective arousal a client diaplays (i.e. Intensity & duration). Need to help canine a client’s emotional development.

Finally, Ingram, (2012) also discusses Carl Rogers’ Humanistic Psychology, culture & emotion as well as emotional competencies.

Treatment Planning:

“Bring in an emotionally connected relationship based on empathetic attunement and support enhances the person’s capacity to feel without needing to develop strategies to minimize or numb emotions. (Ingram, 2012).”  Client needs to develop an ability to accurately understand their feelings and express them in a healthy way.  Gestalt and EFT discussed here.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment ​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Attachment Interventions

Attachment Theory Overview

Based on the work of John Bowlby and Mary Ainsworth, Attachment Theory states that early experiences with primary caretakers during infancy provide a “working model [of oneself] and others” (Broderick & Blewitt, 2006). It is also worth noting that the concept of attachment, as described here does not pertain to a specific set of observable behaviors. Instead attachment is a system of beliefs that sure the purpose of an emotional bond known as “proximity maintenance…[in addition to a] safe haven…[and]…secure base” (Broderick & Blewitt, 2006, p125) with which to interact with one’s world Instead have profound effects throughout one’s lifetime. It is for this reason, an individual’s early attachment experiences have profound affects that last a lifetime. ​It is in the early social interactions with primary caregivers during infancy that we first learn trust others and develops a capacity for emotional regulation. Mary Ainsworth’s research utilized a measure called the “strange situation test” (Broderick & Blewitt, 2006, p126). Based on her observations four types of attachment styles have been observed. Babies with secure attachments show distressed when separated with a caregiver and are easily comforted upon her return so they are able to return to their play activities (Broderick & Blewit, 2006; Ingram, 2012). Anxious-Ambivalent attachments, like securely attached babies are distressed when their caregiver leaves. However, when they return, they are more anger and resistant to their caregivers attempts to provide comfort (Broderick & Blewit, 2006; Ingram, 2012). Infants with Avoidant Attachments do not cry when separated from their caregiver and ignore them when they return in the room (Broderick & Blewit, 2006; Ingram, 2012). Finally Disorganized Attachments are seen in an infant’s tendency to avoid a caregiver when they approach while seeking them out if stressed (Broderick & Blewit, 2006; Ingram, 2012).

Goals for Attachment Interventions​

A primary goal of attachment theories, regardless of one’s developmental stage is the consistent availability and access to an attachment figure (Cassidy & Shaver 1999). However it is important to note that an individual’s “assessment of availability” (Cassidy & Shaver, 1999, p39). changes throughout life. For example, during infancy availability is equated to physical proximity and consistent responsiveness from a primary caregiver. As we mature, the perception of availability pertains to communication and the cognitive appraisal of responsibility to relationship and emotional needs (Cassidy & Shaver, 1999).

For purposes of intervention in order to address disruptions in attachments it is important to assess the individual’s “current appraisal (Cassidy & Shafer, 1999, p39) of their attachment. As a current working model that influence’s one’s relationships, this construct varies and changes in response to relationship experiences throughout life (Cassidy & Shafer, 1999, p39). Intervention goals vary in accordance with: (1) an individual’s current relationship experiences and (2) their developmentally relevant methods of assessment of an attachment figures availability and inherent trustworthiness. Overall, goals center around the disruptions in present attachments and their long-term consequences for a relationship (Cassidy & Shafer, 1999).

Attachment Theory Interventions

One example of a Parent-Child Attachment Intervention is the “Steps Toward Effective Enjoyable (STEEP) Program” (Cassidy & Shafer, 1999, p565). The primary interventional goal for this program is to address a mother’s “working model of attachment by focusing on her feelings, attitudes and representations of the mother-child relationship” (Cassidy & Shafer, 1999, p565). Involving regular home visits staring around the later trimesters of a woman’s pregnancy and into early infancy. It takes a proactive approach. Participants include those who are at greater risk for parenting issues based on prior history. Individual and group sessions allow the individual to alter their beliefs about self and relation to others in order to prevent repeat experiences of old family history.
​Attachment Interventions for adults in individual psychotherapy can include, for example the work of Mary Main who describes three types of parental attachments towards children: “autonomous, dismissing and preoccupied” (Cassidy & Shafer, 1999, p565). Interventions utilized in Mary Main’s approach include metacognitive exercises that ask individuals to consider the working models and belief systems guiding their parental efforts. “Reflective functioning” (Cassidy & Shafer, 1999, p581), is an example of another intervention that involves reviewing life events and evaluating it from everyone’s perspective. Finally, interventions can also be aimed at allowing mothers to develop an understanding of their mental state and a child’s needs (Cassidy & Shafer, 1999).

Attachment Assessments

One convenient example of attachment assessments in early infancy, includes the work of Mary Ainsworth, as described earlier. With this in mind, they involve analysis of child-parent interactions and the stability of observable behaviors over time. As individual’s progress assessments such as “The Cassidy-Marvin System” (Cassidy & Shafer, 1999, p297), are useful. This assessment involves categories of attachment styles similar to Ainsworth’s but for individuals in early child and more diverse display of behavioral responses (Cassidy & Shafer, 1999). Attachment assessments for adolescents and adults, according to the Handbook of Attachment (Cassidy & Shafer, 1999), include a series of narrative interviews. The main goal in this respect is to examine the mental constructs they utilize in current relationships and behavioral responses to these preconceptions (Cassidy & Shafer, 1999).

FINAL QUESTION: “Would a goal of therapy be to increase healthy forms of attachment? Is this possible?”

In a nutshell, based on this book review and overview of interventions/assessments/goals I believe it is possible to work on attachments. An overview of my own attachment history and my husband, shows how fundamentally important this personal construct is in all relationships throughout one’s lifetime. I also believe, in this respect, that addressing it is a worthwhile and fruitful endeavor. One ideal example of the possibility of change is my own husband. His mother was an alcoholic, who died in her forties. Married 8 times in her life, she wasn’t a source of stability for him. Additionally, my husband’s father was never around. Despite this history, and after taking time to address these issues in his own life, he is an amazing husband and wonderful father. He is motivated to create the family he never had. Therefore, I would love to address this issue in my future practice

References

Broderick, P. C., & Blewitt, P. (2006). The life span: Human development for helping professionals. Boston MA: Pearson.
Cassidy, J & Shaver P.R. (1999). Handbook of Attachment. New York: The Guilford Press.
Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Crisis & Trauma

In chapter eight, Ingram (2012) describes five hypotheses that are useful in addressing crises that require “immediate…intervention” (p117). Each of these hypotheses is described below:
  1. An Emergency Hypothesis (CS1), is a situation in which an individual is experiencing homicidal and/or suicidal ideation. An example might be if you are seeing a new client for the first time, and they state they are experiencing suicidal thoughts. A careful assessment in this situation is essential, and the patient’s safety becomes a priority alongside mandatory reporting considerations.
  2. Situational Stressors (CS2) refer to life situations and/or stressors that are in excess of an individual ability to cope. One example might be a very contentious divorce. The loss of a significant relationship, financial strain and restructuring of a family environment can be overwhelming.
  3. Developmental Transitions (CS3) – refer to crises associated with normal human development. Erickson’s developmental theory is useful here as an underlying theoretical perspective for this hypothesis.
  4. Loss and Bereavement (CS4) – As someone who has works in healthcare I’m aware of the crisis associated with the death of a loved one. The grief and morning process occur in stages very much as Kubler-Ross describes
  5. Trauma (CS5) – As I understand trauma, it is an experience that changes how an individual perceives oneself and the world around them. Examples can include anything from rape, natural disaster, combat experience, child abuse, or even vicarious trauma experienced by emergency service worker.

The First Decision….

“Is this someone who needs an immediate, active intervention in order to prevent harm in the client or to others, or can I safely conduct my usual intake and therapy procedures.  There are two errors that must be avoided: (1) failing to prevent serious consequences, including death, destructive actions, and long term pathology by not promptly responding in crisis mode and, (2) pathologizing a condition that, while painful and debilitating, is best understood as a normal, expectable response to the stressors, transitions, and traumas of daily life (Ingram, 2012, p. 117)”  

A careful reading of the five hypotheses in chapter eight is useful in determining the nature of a client’s “crisis” and the associated needs. For all individuals, it is essential to assess for the presence of an emergency situation that produces a concern for the client and/or others. In the instance that a client expresses homicidal and/or suicidal ideation a thorough assessment is necessary. An examination of relevant stressors, suicide plan, presenting symptoms and past history, are key elements of a suicide risk assessment (Ingram, 2012, p120). Homicidal ideation also requires careful assessment and raises mandatory reporting concerns. Finally, evidence of child abuse also requires careful assessment and mandatory reporting. In order to adhere to all legal and ethical obligations, it is essential to be knowledge of the laws in your state and the ACA code of ethics.

In the event that a situation is not a true emergency, guidelines for the situational stressors and trauma hypotheses are useful.  Ingram, (2012) states these to hypothesis are based on crisis intervention literature which notes that “distressing impairment” (p. 117) of this magnitude are a byproduct of either situational stressors or developmental transitions.    Crises of this nature can be described as developing in the following stages:

  1. “STAGE ONE:  Rise in tension & stress.
  2. STAGE TWO: Unsuccessful coping.
  3. STAGE THREE:  Unsuccessful mobilization of emergency solutions.
  4. STAGE FOUR:  Disorganization & Crisis (Ingram, 2012, p. 118).”

Finally, while bereavement may be classified as a developmental transition Ingram, (2012) notes that there are theoretical models specifically designed to address this issue.  Trauma is also addressed as a separate hypothesis in acknowledgement of the obvious fact that stress and trauma are different things.

Emergency (CS1)

Summary & Key Ideas

In this instance, “the client presents an emergency [and] immediate action is necessary.  [It] must always be considered in first session to prevent serious consequences of not taking action”  (Ingram, 2012).  What follows are examples of situations in which this hypothesis may be applicable:

  1. Homicidal & Suicidal Risk.
  2. Mandated Reporting Requirements [i.e. abuse].
  3. Grave illness requiring immediate medical care.
  4. impaired judgment/disability & unable to care for basic needs.

In other words, is the client a danger to himself and/or others?  Are they unable to perform basic ADL’s? Ingram, (2012), suggests that practitioners know the mandatory reporting laws in their state, and how this pertains to confidentiality limits.  Additionally, when feasible consulting with a colleague or supervisor is essential.

Is this Hypothesis a Good Match

This hypothesis is ideally suited for situations in which a person is a danger to self and/or others.  It is also useful in situations where someone is unable to care for their own basic needs.  This hypothesis should be considered during the first session due to the potential negative consequences.

Treatment Planning

Ingram (2012) admits that when making a clinical decision, your best course of action is never  entirely clear!  Human beings are, by nature, complex.  Predicting someone’s future action is ultimately a your best-educated guess.   Two rules of thumb for the newbie: (1) better safe than sorry & (2) seek guidance from your clinical supervisor.  Generally speaking, this hypothesis focuses on people who (1) are a danger to themselves, (2) are a danger to others or, (3) are unable to meet their basic needs.  What follow is a quick-&-dirty list of issues you may need to wrestle with.

  1. Should I hospitalize?
  2. How can I maintain a therapeutic alliance while ensuring safety?  
  3. Risk Assessments
  4. Reporting violence & abuse 
  5. Ensuring client safety and well-being
  6. Mandatory reporting rules of law

Situational stressors – (CS2)

Summary & Key Ideas…

With this hypothesis it is important to examine whether or not the client’s symptoms are proportional to the level of stress they experience?  What are the specific stressors they are struggling with?  How well are they able to cope with the stress?  Examine any risk and/or protective factors that influence their ability to cope with stress.

Is This Hypothesis a Good Match

How does the situational stressor influence the client’s ability to cope?  Examine behavioral, cognitive, and emotional reactions to the stress.  How does the stress affect the individual’s overall well-being.  A convenient example you might compassion fatigue.

Treatment Planning

FIRST PRIORITY  Resolve the Situational Stressor that overwhelms the client’s ability to cope.  Ingram (2012), lists the following as steps for crisis intervention.

  1. “Instill Hope and give reassurance” (Ingram, 2012, p. 129).
  2. “Be in charge of the interview, provide structure, and present yourself as a problem-solving expert” (Ingram, 2012, p. 129).
  3. “Assess the crisis” (Ingram, 2012, p. 129) and help the client make sense of their situation.
  4. Allow the client an opportunity to prcess their thoughts and feelings.  
  5. Help the client to re-examine their perspective of things, (i.e. cognitive restructuring).
  6. “Develop a plan of action” (Ingram, 2012, p. 129) and help the client improve their coping skills and support system.
  7. Finally, monitor the client’s progress and plan with discharge in mind.

Developmental Transitions (CS3)

Summary & Key Ideas…

This clinical hypothesis is based on the developmental lifecycle theories that stress how humans progress through a series of stages in life!  Each stage builds on the one before it and involves a key challenge to overcome, (i.e. midlife crisis).  What follows is a list of terms and key ideas from theories upon which this clinical hypothesis is based.  It tends to focus on an individual model of development that normally occurs over a life span.  However, this developmental model must be placed within the proper cultural and historical context to be relevant to the client.  Gender differences also influence this process.

  1. “MATURATION: through the lifespan involves change, tension, stress and disruption of harmonious living, followed by periods of consolidation and stability
  2.  DEVELOPMENTAL – transitions are triggered by physical growth, psychological maturation, and social pressures and expectation
  3. STAGE – implies a fixed, linear sequence where one stage is completed before the next begins (i.e. Erickson and his concepts of disequilibrium/equilibrium).” (Ingram, 2012)

Is this hypothesis a good fit?

How does one determine if this hypothesis is a good fit?  Ingram, (2012), cautions gains utilizing this model as a preconceived model of growth but as a useful perspective upon which to evaluate an individual’s life history.  it can help us develop an understand the individual’s opportunities for growth and examine issues that were unresolved from previous developmental stages.  What follows are a few examples of common problems that this hypothesis may be a good fit for according to Ingram, (2012).

  1. “Major life decisions” (Ingram, 2012) – (for example having a baby). It can be difficult to make these decisions clearly at times.
  2. “Relationship problems” (Ingram, 2012) – working through relationships problems that develop and/or change as we grow is another developmental issue.
  3. “Cultural Deviation Distress” (Ingram, 2012) – sometimes if a person is deals with negative judgments from a culturally deviant lifestyle.  

Treatment Planning Ideas

Treatment planning should consider the person’s stage of development.  Ingram, (2012), suggests that psychoeducation be provided to help normalize the stress individuals feel when encountering a new stage in life.  Skills training can be helpful in allowing individuals to address new challenges (i.e. parenting challenges) if a skills deficit is uncovered (BL3).  Examining the client’s personal beliefs and feelings regarding the new stage in life is also useful.  Finally, where necessary, films, books, and community resources may be useful.

Loss and Bereavement (CS4)

Summary & Key Ideas…

The next crisis-related clinical hypothesis in the Ingram, (2012) textbook pertains to loss of a loved one or a catastrophic injury (quadriplegic).   Loss of this kind are both internal and external.  Knowledge about the stages of grieving is useful, however Ingram, (2012) cautions therapists to not a “rigid model of grieving”.  Hospice care, bereavement groups, are a few examples of resources that may be utilized.  Initial stages tend to involve feelings of shock and disbelief.  Over time feelings of pain, despair and depression can take over.  Resolving the loss can also involve swinging between denial and despair. What follows are a few related concepts…

  1. Key tasks in the grieving process:  
    1. “Accepting the reality of loss
    2. Working through the pain of grief
    3. Adjust to an environment that includes memory of loss
    4. Emotionally relocate that which was lost and move on…(Ingram, 2012)”
  2. Dual process theory for bereavement: As stated earlier, bereavement means working through feelings of shock, pain, disbelief, and despair.  It requires working through and processing feelings of loss alongside learning to cope and continue moving forward in the world.  This theory describes it as a loss orientation and restoration orientation.  
  3. Three types of complicated bereavement
    1. Chronic Type – too much focus on loss and lack of progress in restoration tasks
    2. Delayed, Inhibited / Absent – too little focus on loss with exclusive focus on restoration tasks.
    3. Traumatic type – intense and persistent confrontation with loss combined with avoidance.

Is this hypothesis a good fit?

Ingram, (2012) begins by providing a list of risk factors that are commonly associated with a complicated bereavement process: (1) the type of relationship with the deceased, (2) circumstances of death, (3) how the person copes with death, (4) other life stressors, and (5) inadequate social support.  Ideal circumstances in which to utilize this hypothesis include when an individual has difficulty coping with the loss and they are experiencing an incomplete recovery.  Examples of situations in which it may be useful can include; (1) divorce, (2) miscarriage, (3) death,(4) infertility, or (5) terminal illness.

Treatment Planning ideas…

  1. Evaluate the client’s level of distress, while providing empathy and room to process the feelings…
  2. Examine skills deficits in how the person is coping.  Consider DBT/CBT skills
  3. Provide psychoeducation on the grieving process. 
  4. Help the client cope with current relationships and life responsibilities.
  5. Restoring the client can involve revisiting experiences and promoting sense of connection to deceased. 
  6. Bereavement groups, CBT/existential/Psychodynamic (Ingram, suggestions). 

Trauma (CS5)

Summary & Key Ideas…

Click here to read a brief explanation of PTSD.  This clinical hypothesis focuses on trauma survivors who experience persistent distressing impairment as a result of traumas they have experienced. Treatment interventions can involved group therapy, spiritual interventions, EMDR, exposure therapy and CBT/DBT.  Ingram, (2012) states: “the concept of PTSD implies an etiologic process whereby pathogenic memory produces involuntary, distressing recollections in the form of intrusive thoughts, nightmares, flashbacks…etc…These recollections heighten emotional arousal….This…in turn, motivates attempts to avoid anything that might trigger recollections.”

  1. Risk factors:  “Severity of stressor, Prior vulnerability factors, Subjective Threat level, Lack of Social Support.” (Ingram, 2012).
  2. Protective factors: “effective coping skills, social support, spiritual factors, sense of self.” (Ingram, 2012).
  3. Cultural context: “Ethnocultural variables are important when assessing trauma history of survivors. Cultural factors can interfere and prevent effective interventions” (Ingram, 2012)..

How To Determine fit?

Ingram, (2012) begins by noting that trauma is harmful regardless of whether a person has symptoms of a diagnosis.  With this in mind, addressing the client’s problem first involve examining the specific symptoms they are experiencing, (trouble sleeping, emotionally numb, depressed, etc).  Then gather data about their trauma history, “avoid extremes in neglecting the topic and addressing it with insensitivity” (Ingram, 2012).

Treatment Planning Ideas…

“WARNING BEFOREHAND: Trauma interventionists need special training, competent supervision or consultation, and ongoing professional support. The need to be aware of the risk of vicarious trauma….” (Ingram, 2012).  With this in mind, my textbook provides an overview of three categories of interventiosn…

  1. “Critical stress debriefing immediately after trauma” (Ingram, 2012).
  2. “Treatment of PTSD Symptoms” (Ingram, 2012).  
  3. Treatment of complex PTSD” (Ingram, 2012). 

Treatment of PTSD requires multiple clinical hypotheses:  (1) Medical Interventions (BE2), (2) Mind-Body Connections (BE3), (3) Emotional Focus (BE4), (4) Conditioned Emotional Responses (BL2), (5) Cognitive (C1-4), (6) Spiritual Dimension (ES3), (50 Social Support (SC3).  Education/Medication/Exposure/CBT/EMDR/Relational psychotherapy.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Clinical Hypotheses

“The ‘H’ in the acronym SOHP stands for hypothsis section – a shorter heading than formulation discussion that incorporates clinical hypotheses.  As explained in Chapter 1, all theories are bundles of hypotheses.  You have several choices for creating your formulation: (1) use a formulation that is based on a single theoretical approach; (2) use a ready-made integrative formulation; (3) use an empirically supported treatment model; (4) create your own integrative formiulation” (Ingram, 2013, p. 87).

What is Hypothesis?

“A Hypothesis is a single explanatory idea that helps to structure data about a way that leads to better understanding, decision making and treatment choice.” (Ingram 2012 p. 111).  Ingram, (2012), suggests utilzing a three page worksheet to organize your thoughts with: (1) data in the first column; (2) hypotheses in the second column; and (3) ideas for a plan in your final column, (p. 86).

Common Errors…

This system is useful in preventing you frm developing hypothess that have no basis in data you have gathered.  There are three common errors therapists make according to Ingram, (2012).

  1. ERROR #1:  The formulation/hypothesis lacks supporting data.
  2. ERROR #2: The formulation is not supported by data.
  3. ERROR #3:  The formulation omits a strong hypothesis.

Common Mistakes…

  1. “The hypotheses section does not introduce new data” (Ingram, 2012, p. 90).
  2. “The hypothesis section focuses on the specific problem of the specific client” (Ingram, 2012, p. 91).
  3. “Hypotheses all lead to treament plans” (Ingram, 2012, p. 92).
  4. “Hypotheses are discussed with professional-level thinking and writing skills” (Ingram, 2012, p. 94).

 Book contains 30 hypotheses in 7 Categories…

Thes hypothes are based on theories of psychotherapy, new approaches, and empirically suported treatment (Ingram, 2012).   Each category begins with an overview of the theory and/or empirically supported treatment it is based on.  For example, the Behavior and Learning Models are based on behavioral analysis and therapy.  Key concepts from this theoretical perspective are discussed at the beginning of the chapter for review before the hypotheses falling under this category are reviewed.    Each hypothesis the begins with a summary that includes a title, definition, explanation, and examples of cases for which this hypothesis is applicable.  Next under each hypothesis is a discussion of key ideas, treatment planning ideas, and tips to determine its usefulness and applicability in specified cases, along with suggested readings.

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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MCC 670 – Treatment Plan

​The Purpose of a Treatment Plan…

The purpose of a treatment plan is to address the “HOW of therapy” (Ingram 2012 p. 95).  It acts as a guide for the counselor throughout the therapy process.  When developing your treatment plan, it is useful to look at the information gathered from your IDI and ask how this strategy can help the client achieve their goals?  Or in other words, what problems is it designed to address?

BOOK EXAMPLE:  “In order to help the couple effectively manage conflict…(Outcome Goal), I will use Hendrix’s imago therapy (Strategy)…Family therapy is the treatment of choice (Strategy) to reduce Johnny’s Oppositional Behavior (Outcome Goal).

Standards for Creating a Treatment Plan…

  1. STANDARD #21: The plan is focused on resolving the identified problem and achieving outcome goals” (Ingrams, 2012, p. 95).
    1. Does strategy stray from plan?
    2. Write strategy and problem in one sentence (see above).
  2. STANDARD #22:  The plan follows logically from the hypothesis and does not introduce new data.
    1. Does your plan have no “foundation in the hypothesis section? (Ingram, 2012, p. 98).
    2. Do you have a hypothesis with no plan to address it? (Ingram, 2012).
    3.  If you see new data in plan, need to add to database, or eliminate it from the plan.
  3. STANDARD #23;  The plan is informed by knowledge of research literature.” (Ingram, 2012, p. 99).
    1. Check remaining posts from MCC 670.  They provide examples of how relevant research and theory can guide your treatment plan.
    2. Evidence Based Practices are required by third-party payers…
  4. STANDARD 24:  There is clarity regarding strategy, sub-goals and process goals; procedures and techniques; priorities and sequencing and the desired client-therapist relationship” (Ingram, 2012, p. 100).  What follows are a few relevant considerations…
    1. New therapists might include more information to guide their efforts.
    2. The number of sessions allowed by insurance and affect how much detail is required.
    3. Some clinical hypotheses requre more detailed and specified plans.
    4. “The plan should describe what kind of relationship is desired and what should be avoided” (Ingram, 2012, p. 101).
    5. Specify the sequence of interventions in your plan (Early/Middle/End).
  5. STANDARD #25: “The plan is taylored to the specific client; Such factors as gender, ethnicity, sexual orientation, and spiritual are considered” (Ingram, 2012, p. 103).
    1. Cultural Competency is important in the development of rapport (I.e. language, relationships, metaphors, relationships, boundaries, body language) and to create strategies relevant to the client.  (Ingram, 2012).
    2. Other considerations:  Stages of change; amount of structure; and levels of authority displayed by the therapist (Ingram, 2012).
  6. STANDARD #26:  The plan is appropriate for the treatment setting, contractual agreements, and financial constraints” (Ingram, 2012, p. 107).
    1. What is insurance willing to prove?
    2. WHat sort of therapy modality is utilized at your facility?
    3. What are the clients motivations, expectations, and resources?
  7. STANDARD #27: The plan incorporates community resources and referrals” (Ingram, 2012 p. 108).  Be aware of community resources available….
  8. STANDARD #28:  The plan addresses legal, ethical and mandated reporting issues.” (Ingram, 2012, p. 109).  Be knowledgeable of legal and ethical standards…

A Sample Treatment Plan…

Client Last Name, First Name, MI: Jones, Illana, T.

Address: 1234 Something Street

City, State, Zip: Everywhere, NE 12345

Telephone (s): (402)-123-4567

Parent/Guardian (if client is a dependent): N/A

Informant (if other than the client): N/A

Client SSN: 111-11-1111

Place of Birth: Indianapolis, Indiana

Date of Birth: ​09/21/1986​​​

Age: 28

Gender: ​Female​​​​

Race: Hispanic/Latino

Chief Complaint/Presenting Problem:

Client is a 28-year-old mother married mother of two young children, who currently lives in base housing. She has been referred by the base doctor after complaining of depressive symptoms and failing to contract for safety. She appears significantly underweight, cries easily and complains of a debilitating depression.

Diagnostic Impression:

• 296.32 (F33.1) – Major Depressive Disorder, Severe, Recurrent Episode
• 307.1 (F50.02) – Anorexia Nervosa, Binge-eating/Purging type, Moderate.
• 995.53 (T74.22XA) Child Sexual Abuse, Initial Encounter
• V15.59 (Z91.49) Personal History of Self-Harm
• Rule Out – Suicidal Behavior Disorder

Case Formulation (biopsychosocial history and MSE) Summary:

Biopsychosocial History
  1. Emotional/Psychiatric History – The client’s psychiatric background includes a diagnosis of major depression, anorexia nervosa, and self-harming behaviors. History of self-harm includes cutting behavior and a distant hospitalization in eighth grade for a suicide attempt. Cutting behavior onset in eight grade, includes small cuts and eraser marks on skin to relieve stress. Significant history of anorexia, binge-purge type, starting in eighth grade. Latest psychiatric hospitalization to stabilize anorexia after her daughter’s birth when she gained 40 pounds. Previously prescribed antidepressants, but stopped taking them. Is not currently being followed by a mental health provider. Her current symptoms include feelings of worthlessness, social isolation, fatigue, and suicidality with no plan in place. Patient is also notably tearful and significantly underweight.
  2. Social History – Ilana is a 28-year old stay-at-home mother of two young children ages 3 and 5. She has been married to her husband, David, for seven years. She recently moved into base housing three months ago, after a series of job-related transfers due to her husband’s line of work. Describes the frequency of these transfers as difficult for her, and complains of isolation after their latest move.
  3. Family of Origin: The client was born to Umberto and Guadalupe, restaurant owners in a small Midwest town. She reports her early childhood as mostly “idyllic” and states her large extended family played a significant role in her daily life. Her older sister, Reyana is just two years her senior. Ilana describes an unhealthy competitive relationship with her sister and feeling like the “ugly duckling”. Mother’s concern for her weight at this time further exacerbated these insecurities. Ilana’s eating disorder history has an onset at about this time as well.
  4. Academic & Intellectual History – Ilana’s academic history is unremarkable. She reports she was a always a good student. Holds a bachelor’s degree in psychology.
  5. Employment History – The client is a stay-at-home mother with no recent employment history and no plans to return to work with two young children at home.
  6. Cultural and Religious Background – Ilana describes herself as “not very religious” although states she was raised in a large Catholic family. While Ilana grew up in a small predominantly white community, she was raised by a large Hispanic family with rich cultural traditions. She expresses great appreciation for this culturally diverse background.
  7. Medical History – Ilana’s developmental history is largely unremarkable. Ilana mentions a growth spurt in junior high resulting in a significant weight gain, at which point her mother started her on Weight Watchers. Pregnancies described as difficult due to weight gain and exacerbation of eating disorder symptoms. Hospitalization required after oldest child to stabilize eating disorder symptoms. Youngest child born two months early, resulting in exacerbation of depressive symptoms.
  8. Legal History – N/A
  9. Offender Issues – N/A
  10. Victim Issue – Ilana reports an incidence of sexual abuse involving fondling by a great uncle when she was five. While she remembers little about the incident, she states her family was quite emotional and entered counseling as a family to address this issue.
  11. Substance Abuse History – Ilana does not drink, smoke, or use illicit drugs.
Mental Status Exam
  1. Appearance – The client is a well-groomed 28-year-old female who appears her stated age. Is extremely underweight with cuts marks along inner thighs and arms.
  2. Behavior – Crying and tearful throughout the interview.
  3. Cooperation – Client is cooperative throughout the interview although mentions her reluctance to be here.
  4. Speech & Language – Client’s speech is articulate and coherent. Nonetheless, she is minimally responsive to the therapist’s questions.
  5. Thought Form & Content – Thought processes are goal-directed and coherent. Transient thoughts of self-harm with no plan in place.
  6. Mood & Affect – Mood and affect appear congruent. Client complaints of debilitating depression and is tearful throughout interview.
  7. Perception – Unremarkable.
  8. Level of Consciousness – Client is alert and oriented.
  9. Insight & Judgment – Partial insight noted in light of limited capacity to understand underlying issues. Judgment poor in light of inability to make reasonable decisions pertaining to adequate self-care.
  10. Cognitive Functioning – Unremarkable.
Problems (specific concrete behaviors):
  1. Unmanaged Depression
    1. As evidenced by Psychological Evaluation
    2. As evidenced by depressive mood and affect.
    3. As evidenced by suicidal ideation.
    4. As evidenced by feelings of worthlessness and isolation.
  2. Inability to maintain healthy weight
    1. As evidenced by BMI of 16 during doctor’s exam.
    2. As evidenced by report of binging and purging behaviors.
    3. As evidenced by inadequate food intake.
  3. Difficulty coping as manifested in cutting behavior.
    1. As evidenced by visible cuts on arms and thighs.
    2. As evidenced by client’s report of cutting behavior to “feel better”.

Hypotheses (etiology):

  1. Exacerbation of depression due to poor understanding of underlying symptomatology and discontinuation of medication.
  2. Increase in suicidal ideation and cutting behavior due to deficient coping skills and ongoing rumination with poor metacognitive insight into thought processes.
  3. Re-emergence of eating disorder behavior due to poor self-care, low self-worth, and a feeling out of control with binging and purging habits. Onset associated with competitive relationship with sister, and criticism from mother for weight gain in junior high.

Treatment Goals (mutual):

  1. PROBLEM – Unmanaged Depression
    1. GOAL ONE – Symptoms of depression will be significantly reduced until they no longer impede with daily functioning.
      1. OBJECTIVE ONE: Ilana will take all medication as prescribed and attend all scheduled meetings this month.
      2. OBJECTIVE TWO: Ilana will develop increased understanding of maladaptive thought processes underling depressive feelings as a result of participation in DBT Skills Group.
        1. INTERVENTION: Therapist provides referral to DBT Skills Group and forwards case information to provider, Jane Doe LMHP.
          o Responsible Party – Kathleen Johnson, Future LMHP
        2. INTERVENTION: Jane Doe, LMHP monitor’s Ilana’s progress and provides her therapist with relevant updates
          o Responsible Party – Jane Doe, LMHP
      3. OBJECTIVE THREE Ilana will develop a safety-plan with her husband and report no suicidal thoughts for one month.
    2. GOAL TWO – Overcome resistance to therapy, and develop solid therapeutic relationship as evidenced by commitment to therapy and open communication.
      1. OBJECTIVE ONE: Ilana will discuss with therapist the nature of her resistance to therapy in this month’s sessions.
      2. OBJECTIVE TWO: Ilana will discuss what she hopes to achieve in therapy and commit to active participate
      3. OBJECTIVE THREE: Ilana will discuss her concerns and any areas of disagreement with the therapist should they come up at any point in time.
  2. PROBLEM – Inability to Maintain Healthy Weight
    1. GOAL ONE – Restore healthy body weight.
      1. OBJECTIVE ONE: Ilana will visit her physician weekly for regular weigh-in’s.
        1. INTERVENTION: Physician will monitor Ilana medically and forward information as necessary to her therapist.
          o Responsible Party – Base Doctor.
      2. OBJECTIVE TWO: Ilana will record her daily dietary intake with her husband’s assistance and monitoring.
      3. OBJECTIVE THREE: Adherence to dietary recommendations of primary care physician as indicated by food log.
    2. GOAL TWO – Reduce binging and purging behavior.
      1. OBJECTIVE ONE: Client will closely monitor self care, listen closely to her bodily cues.
      2. OBJECTIVE TWO: Ilana will avoid people and places that tend to trigger any urges to engage in binging and purging behavior.
        1. INTERVENTION: Therapist will assist Ilana this month in developing a list of triggers for her binging and purging behavior.
          o Responsible Party: Kathleen Johnson, Future LMHP.
        2. INTERVENTION: Therapist will assist Ilana in developing strategies to avoid these triggers.
          o Responsible Party: Kathleen Johnson, Future LMHP.
    3. GOAL THREE – The client will build a healthy self-esteem.
      1. OBJECTIVE ONE: Eating disorders will no longer be the focus of her interactions with sister and mother.
      2. OBJECTIVE TWO: Ilana will develop positive self-talk and healthy coping strategies.
  3. PROBLEM – difficulty coping as manifested in cutting behavior
    1. GOAL ONE – Gain insight into the reasons for cutting behavior.
      1. OBJECTIVE ONE: Ilana will develop greater emotional awareness and learn alternative methods for regulating emotions.
        1. INTERVENTION: Ilana will learn emotional regulation skills in a weekly DBT Skills Group.
          o Responsible Party: Jane Doe, LMHP
        2. INTERVENTION: Therapist will discuss with Ilana, her DBT Skills Group homework in individual sessions.
          o Responsible Party: Kathleen Johnson, Future LMHP
      2. OBJECTIVE TWO: Ilana will identify a list of self-harm triggers with her therapist next session.
    2. GOAL TWO – Find alternative methods of coping as a healthy replacement for cutting behavior.
      1. OBJECTIVE ONE: Ilana will utilize DBT skills in order to regulate emotions in a healthy manner.
      2. OBJECTIVE TWO: Ilana will develop a list of soothing techniques, to calm persistent negative feelings with her therapist during the next session.
      3. OBJECTIVE THREE: Ilana will work develop a list of activities that can allow her to release or expressing painful emotions during the next session.

Supports:

The client’s extended family is very supportive. She has a loving husband and is motivated by her desire to be a good mother to her children.

Obstacles

Ilana’s reluctance to seek therapy is concerning. Additionally she displays low self-esteem as evidenced by her assertion that “I’m a terrible wife and mother”. These statements are also indicative of low insight into the affect of depression on her thought processes.

Additional Information Needed

Treatment team includes Ilana’s base doctor who will monitor her weight regularly. In-house Psychiatrist will follow for pharmaceutical treatment of depression. Jane Doe will also be conducting a weekly skills group, which Ilana expected to participate in.

Assessment Measures to Track Progress

Ilana will visit her base doctor weekly for weight monitoring. Psychiatrist will assess client monthly to monitor her response to medications. Therapist will assess client’s depressive symptoms and suicidal ideation monthly in order to determine her baseline.

Treatment (model, location, therapist style, focus, frequency)

Individualized therapy to occur weekly in conjunction with weekly DBT group meetings.

Pharmaceutical Treatment

Client is referred to in-house psychiatrist for evaluation this week. Pharmaceutical Treatments to be determined at this time.

Adjunct Treatment(s), (e.g. support groups)

Client referred to Dialectical Behavioral Therapy Skills Group as an adjunct treatment to individualized therapy. Information on eating disorder support groups has also been provided.

Prognosis

Prognosis guarded due to the client’s reluctance to participating in therapy and inadequate following through with treatment recommendations. The multifactorial nature of Ilana’s issues significantly increases the need for close management and ongoing support.

_____________________________​______________
Signature, Title​​​​​/Date

References

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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