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Example: DATA- O=report by others, S=self-report, hx=history, AEB= as evidence by

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STEP 1: Problem Identification

(S) Hx: Acculturation of Humanity	(o) “Data has been acting sluggish”	(o) Boss “Concerned about ability to function effective at post” (Work)	(o) “Appears to feel empty”
(o) “no longer interested in intellectual jousting”	(o) “no longer interested in recreation”	(o) “moves slowly about everyday tasks”	(s) Suicidality AEB: wants to “Just shut off”
(o) “Large memory gaps do to procedure”	(o) hx: unconventional childhood	(s) hx: identified with Pinocchio/ longing to be “real”	(o) hx: of stealing (emotion chip)
(o) hx: memory loss	(o) Vast intellect	(O) translates languages	(o) fearless
(o) Great strength	(o) hx.: Flashbacks	(O) hx. Awards for good work	(O) hx. Of the label of “Human”
(O) “Sad”	(o) sluggish movements	(o) ruminations about “Shutting off”	(o) resisting temptation to self-harm
(o) feeling sad for 3 weeks	(s) can’t think/concentrate	(S) can’t effectively work	(s) low energy
(s) fear of abandonment by friends	(s) “Cant’ relax”	(s) wants to cry but cant	(s)”memory loss effecting self-advancement”
(s) has no energy for reflection on “God and the Universe”

STEP 2:Thematic Grouping

Descriptive Diagnosis	Clinical Target	Areas of fx/dysfx	Intrapsychic
(o) “Data has been acting sluggish”	(o) “Data has been acting sluggish”	(o) Boss “Concerned about ability to function effective at post” (Work)	(S) Hx: Acculturation of Humanity
(o) “Appears to feel empty”	(o) “Appears to feel empty”	(s) Suicidality AEB: wants to “Just shut off”	(o) “Large memory gaps do to procedure”
(o) “moves slowly about everyday tasks”	(o) “no longer interested in intellectual jousting”	(o) “Large memory gaps do to procedure”	(o) hx: unconventional childhood
(s) Suicidality AEB: wants to “Just shut off”	(o) “no longer interested in recreation”	(o) hx.: Flashbacks	(s) hx: identified with Pinocchio/ longing to be “real”
(o) hx: memory loss	(o) “moves slowly about everyday tasks”	(o) ruminations about “Shutting off”	(o) hx: of stealing (emotion chip)
(o) hx.: Flashbacks	(s) Suicidality AEB: wants to “Just shut off”	(o) resisting temptation to self-harm	(o) Vast intellect
(O) “Sad”	(o) hx.: Flashbacks	(S) can’t effectively work	(O) translates languages
(o) sluggish movements	(o) sluggish movements	(s)”memory loss effecting self-advancement”	(o) fearless
(o) ruminations about “Shutting off”	(o) ruminations about “Shutting off”		(o) Great strength
(o) resisting temptation to self-harm	(o) resisting temptation to self-harm		(O) hx. Awards for good work
(o) feeling sad for 3 weeks	(s) can’t think/concentrate		(O) hx. Of the label of “Human”
(s) can’t think/concentrate	(S) can’t effectively work
(S) can’t effectively work	(s) low energy
(s) low energy	(s) fear of abandonment by friends
(s) “Cant’ relax”	(s) “Cant’ relax”
(s) wants to cry but cant	(s) wants to cry but cant
	(s) has no energy for reflection on “God and the Universe”

4 D’s

Deviance: NA Danger: Harm to self Dysfunction: Work, Suicidality, Flashbacks Distress: Harm to self

Diagnosis:

With the manifestation of multiple depressive symptoms over a three week period since Data has been labeled human, including ruminations on suicide, the diagnosis of best fit is Major Depressive Disorder- specifier Severe/ single episode 296.23 (F32.2).

STEP 3:Theroretical Inferences

Psychodynamic- Psychotherapy

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K. R., ... & Wang, P. S. (2003). The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Jama, 289(23), 3095-3105.

Client is choosing: isolation, thoughts of self-harm, not to relax, not to see friends

STEP 4: Narrow Inferences

To cope with the feelings of Major Depression Disorder, Data has chosen to isolate himself, avoid relaxation, avoid friendships, and think about “shutting off.

DOACLIENTMAP

D: 296.23 (F32.2) Severe Major Depressive Disorder- Single episode

O: Goals: Attend therapy, get support for suicidality, schedule time to relax, schedule time with friends

A: Beck Depression inventory

C: Certified mental health profession in area of psychotherapy and knowledge of resources and referrals to suicide prevention networks and android to human acculturation support groups

L: Outpatient with any professional in mental health (Kessler et al., 2003)

I: Individual Psychotherapy (Kessler et al., 2003)

E: Avoid isolation and seek support

N: 8 sessions (Kessler et al., 2003)

T: 30-minute sessions (Kessler et al., 2003)

M: EBP- Best medication- psychotropic medication (Kessler et al., 2003)

A: Suicide prevention network and human acculturation support group

P: According to the DSM (2017) and Kessler et al. (2003), because Data has no biological influences prognosis is that his Major Depressive Disorder can be in full remission after effective treatment.

GOALS:

1 LTG: Learn new 5 new and healthy coping strategies through the 8-session Psychotherapy treatment.

2 STG: Schedule 30 minutes every day to relax on the Holodeck and Schedule time to be with friends at least one day every weekend for the next 6 weeks.

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