Case Formulations & Presentations Unpleasant Family Relationship Case Stuy
Question Description
Attached you can find information about person I would like to use for paper. So your task would be to add this information according to outline plus add more info where necessary, while comparing to the sample paper. Let me know if you can work on it.
CASE FORMULATIONS AND PRESENTATIONS:
Who this person is to you?-friend
How you gonna get information?-interview
What at this point you are formulating? There were a few main areas of concern for the client.These were a lack of support from his family, his inability to accept his experience of unpleasant and sad emotions, and his not understanding of broken family connections.He has a strong attachment to the family, and has an inability to let go of his past relationship.
Outline:
Presenting problem:
Describe in terms of behaviors, thoughts, and physiological response.-DETAILED
Exact number of incidences in day, amount of hair pulled, etc. Details in the behavior and put into objective terms Where, what, how (many), with who (not why!).
Also discuss current triggers context (environment), situational (create hierarchy), behavior cues, thought cues).
History of Presenting Problem:
Only information relevant to presenting problem. Onset and course of illness. When problem started, how , under what condition problem started.
Relevant factors to presenting problem (Development):
Information relevant to the development of the problem. Here you are answering HOW.
Here you are looking at learning theory.
Associated and Maintaining variables:
Here you are answering why does it continue.
How reinforced, etc.
Formulation of the chief complaint:
A summary of the above information describing how it developed, how it is experienced, how it is maintained in a succinct paragraph.
Strengths-resources:
What factors will enhance the efficacy of CBT.
Weaknesses-interferences with treatment:
What factors will interfere with the efficacy of CBT.
Eg, Compliance, physical factors, etc.
Treatment goals:
What you hope to accomplish in measurable factors.
Treatment procedures:
including why they are chosen. Be specific about how to proceed.
How monitored:
Be specific on how you plan to monitor the progress of the treatment and how the tools were chosen.
Sample:
Presenting problem: Pt is a 59 year-old Caucasian female hospitalized for bizarre and paranoid behavior. Specifically, she stopped eating, appeared to be responding to auditory hallucinations, and responded with rage to her family. Just prior to the hospitalization, she left her apartment and drove from Houston to New Orleans to see her son without telling any of her relatives, including her son. She was missing for three days and was found by local police of a small town in Texas after she abandoned her car. She denied any psychotic symptoms when asked directly, but she reported bizarre experiences. For example, she stated that she had died and was resurrected four times. In addition, she reported hearing voices “once in a while” giving her instructions, but believes that they are coming from external sources. It should be noted that during the interview, she frequently mumbled, as if responding to voices, and sometimes laughed during these mumbling episodes.
In addition to these difficulties, Pt has a history of being raped in a car while she was in Belgium 23 years earlier (when she was 36 years old). During the rape, she reported disassociating, and therefore, remembers much details immediately before and shortly after the rape, but little about the actual rape. Shortly after the rape, she developed intense fears. Currently, these fears are triggered by being alone with strange men, being in a car with a male, and being in a reclined position (e.g., in a dentist chair) when a male is near. In addition, about once a month, she hears voices commanding her to perform an action in order to avoid a rape like experience to which she responds with great fear. For example, a voice commanded her to get off the couch or “something gooey” would get in her hair. She reports being chronically on edge and easily startled by sudden noises and continues to have intrusive memories of the rape almost every day. These memories cause her to be agitated and fearful, and she experiences increased heart rate and nausea. She attempts to avoid these thoughts and avoids being alone with males. She experiences little connection with others and reports being irritable for most the day. She reported that the rape has changed her life and that she cannot feel normal feelings anymore. It is for these symptoms related to the rape that she requested therapy.
History of Presenting Problem: Pt returned to the United States a month following the rape. It was upon her return that she remembered experiencing the intrusive memories that led to intense fear. Other symptoms soon developed and intensified. Pt soon began avoiding others, especially males, and refu