for KIM

Case Conceptualization and Treatment Plan

Develop a clear and thorough understanding of the presented case in the video shown in class.

Write a 2,800- to 3,500-word paper using the Clinical Case Study Guidelines document to prepare your analysis of the video presented in class.

Review your notes taken during the counseling session presented in class. Use the DSM 5 and additional professional sources as you explore the client's situation, potential diagnosis, treatment planning, and legal and ethical concerns.

Select a theoretical orientation to complete the analysis of the client.

Discuss the presenting problem from the theoretical perspective, and include language from the theory throughout the case conceptualization. Include the following:

•Summarize the client's background and present living situation, addressing diversity and the human life cycle.

•Discuss the client's present level of functioning and provide examples from the Unnamed Video to support your assessment.

•Identify the client's key problems and issues. Discuss which problems the client is experiencing and why the client is having these problems.

•Propose a theoretical orientation that would be appropriate to use with this client and discuss the theory and application.

•Provide a logical and rational assessment of the client and a diagnosis that is consistent with the assessment. Support the diagnosis using the DSM 5 and other research.

•Identify appropriate goals and interventions that are consistent with the assessment, diagnosis, and theoretical orientation. Discuss how these might be addressed within the treatment sessions.

•Recommend psychometric tools that would be appropriate for further assessing the client's needs based on background and diagnosis. Justify your recommendations.

•Identify thoughts and behaviors that you would use as criteria to determine readiness for successful client termination.

•Identify important legal and ethical issues and propose resolutions. Support your resolutions with appropriate codes of ethics and legal statutes.

•Use peer-reviewed sources to support your ideas throughout the paper.

Format your paper consistent with APA guidelines.

4 goals – 3 short term and 1 long term each having 3 interventions = 12 interventions. No objectives only goals and interventions.

CLIENT NAME: LIZ

DATE OF BIRTH:

PHONE:

PRIMARY LANGUAGE: English

EDUCATION:

REFERENCE BY: Friend

OCCUPATION: Homemaker

ASSESSMENT DATE: 01/05/2017

EVALUATED BY:

DESCRIPTION OF THE CLIENT The client is a 34-year-old woman Hispanic female, dressed casually and neat, clean clothing. She made normal eye contact, she spoke in expressive voice, and appeared sad manifested by tears. PRESENTING PROBLEM The client reports for the past two months her experiencing hopelessness, depression and anxiety because of negative core beliefs that she is inadequate, worthless and a failure. The client reports “I have a lot on my mind, I feel pressure like I cannot breathe sometimes and I get angry with myself because I want to please everyone”. This has resulted in symptoms that are diminishing the enjoyment of her life. The client’s automatic negative thoughts that she is worthless and a failure has caused the client to stop doing things that used to bring her pleasure. The client reports that all of these emotions and conflict is affecting her. The client states she is tearful, always tired; restless; unable to feel pleasure; ambivalent suicidal ideations; anxious, unable to sleep; hopelessness; loss of appetite; despair; and fear.

HISTORY OF PROBLEM The client reports that she and her husband have relationship conflict and communication problems which lead to arguing. The client states “he pushed and slapped me, he said that he would kill me or hurt me in front of my children. I felt the abuse was escalating so I took the children and moved in with my mother”. For the past two years her husband started drinking heavily and the physical abuse is escalating. She has been living in fear that he will kill her. This negative core belief has a caused automatic negative thoughts that allowed years of mental, emotional, and physical abuse from her husband. These automatic negative thoughts have contributed to the client’s depression as a result, she has left her husband and moved in with her mother. The experience of the separation from her husband has triggered negative core beliefs that she is inadequate, worthless, and undesirable, and reinforces, or activates, her automatic negative thoughts.

MENTAL STATUS

What happened to you or made you decide to make the appointment today as opposed to a few months ago? She has not been feeling well don’t have the energy to do things needs more and looking gofer answers she’s here to try to find help and figure out what direction to go with.

What is going on with your life? About 2 months ago she moved out of her home to her parent’s house with her 2 children oldest is 9 boy, and 7 year old girl. Husband is a little abusive, she does not want to be there. She feels safe at mom’s house. Doesn’t know if she did the right thing. She has been married for 10 years.

Tell me a little about the abuse?

Abuse wasn’t big he occasionally pushed her a couple of times slapped her, verbally abusive, escalated it got worst so she ended up leaving.

Was there abuse early on the relationship?

Early in marriage didn’t think it was abuse, we fought argued got in my face pushed in my face didn’t think anything of it. Got worst during the years. (Crying am sorry)

Therapist? Asked if she was afraid to move out? She said she was slapped in front of the kids, hurt her, threatened to kill her and hurt her. Didn’t want kids to see that anymore got scared.

Therapist? Did he abuse the kids? NO. (Seriously) But last time the kids were scared they were yelling at their father to stop! (She’s crying holding back) they did see that and I felt so guilty

Therapist? Good job keeping the kids safe. Has he tried to call? Yes calling her mother’s home and mother tells her she should return his calls and answer his calls. She doesn’t know if she’s taking the kids away from their dad. She feels that she is taking them away. She doesn’t know if she needs to go back home maybe he will change.

Your mother keeps telling her she should go back home. Mother encourages her to go back home. She wishes her mom would stop. She feels angry every time her mother tells her to go back home. Mother feels that kids are missing out on good parenting if she doesn’t go back.

So she’s encouraging you to go back? A little angry at first the more I talk about it I don’t know if it’s the best thing.

Is that what you want or your mother? Sometimes she’s not sure. Sometimes she wants to go back home to feel like a family. At her house she had her family, her house, her space, time. (Crying)

Gives her credit will work to clarify what she wants and needs. Tell me a little about your culture beliefs?

Culture beliefs or spirit believes that are causing you distress? – am Mexican we have certain values, married to stay married she was born in the US or Mexico no here... Sometimes she wonders if her values is the reason to go back home. Her mom has experienced this before she’s wises and has been down the road before. Her own mother has been in an abusive marriage with Liz father. Dad would hit her mom. At times mom would not come out of the room because of the bruises on her body. Her father ended up leaving her mother anyways.

Did he abuse you and how did affect you? Father never abused Liz but witnessed mom abusive life. She plays it in her head and she doesn’t want her kids to feel like her.

So you have been down this road before did your mom ever get remarried? She feels like she is relieving the same story. What if she doesn’t get remarried again Liz mother never got re married, she works, and raised the kids. Liz mother tells her that she thinks she still loves her husband and that is why she should go back. Her dad was pretty abusive her dad would hit her. Everything her mother did was about her kids.

What is one of your strengths personality something that will get you through? I love my kids I love my mom I think I love my husband.

Therapist? Do you have a support group? Not too many friend. One friend her name is Karen. Pretty much there for Liz for the past 1 year. She is funny, crazy normal woman, listens doesn’t judge me, cares and suggested to seek counseling and I dint want to I thought it would be a waste of time but lately I haven’t been feel well I feel like am against the wall.

Feelings? Liz is not feeling well, she feels like she is against a wall right now.

Sleeping? Don’t sleep, wake up can’t sleep last night up till 2am can’t sleep. Feels pressure in head, lots of thoughts, don’t want to be at her mom’s house, feels like she’s not pleasing her mom and her husband and hurting her kids don’t want to do that anymore. She doesn’t want to hurt kids and everyone. (Crying deeper)

Anxiety before it’s like you described it raising thoughts, heart pounding, pressure, not feeing well? Liz stated that it sounds about right. She can’t get up to get the kids ready for school she falls asleep till 2am, thinking about the kid’s feelings all the time. Don’t want to do anything, hard time getting up, feels exhausted no energy, waking up to do the same thing over and over again. Feels like its getting worst since she moved out. It started with her wanting to leave when she finally left.

She wants to leave her mom house, she doesn’t know if kids are happy, kids talk to dad over the phone and she avoids talking to him because he can convince her to come home. So she hasn’t really talked to him

What brings you joy during the day makes you feel good? My Kids, family, sister, she’s cool, friends, younger sister is independent not married with a career, no kids, lives in Washington now. Pretty amazing life. Sister asked her to find a job and move to Washington with her. She doesn’t know if she’s ready for that. Sister is pretty smart and has everything.

What do you think about moving it sounds exciting? I’m not ready for that what do I bring to the table she has a career she’s pretty she’s smart,

Have you ever thought that about yourself? I don’t feel that am pretty and smart like her sister. I only remember getting married and having kids that’s her role that’s her life what will she do out there. She doesn’t want to be extra baggage to her sister.

If you stay or move will you follow your mother’s footsteps? She doesn’t know she didn’t get married to be alone she married to be married and do what’s right. Liz stated if she stays with her husband she’s afraid she will up like her mom. She didn’t get married to have a broken home. She needs to stand up to make it right. She mentioned that her husband Robert is Mexican and that is the values to go by being a Hispanic family.

Husband does apologize after he abuses her and it has gotten worst. Doesn’t know if he meant it or just saying it so she can stay when she was living at home.

It almost sound like you have 2 options – to go back to him or to follow your mom’s steps.

Any possibility of a third any hopes for that? What else could there be, I have no options right now.

Do you have any hopes in your day to day activity that makes you smile or think about the future? Go back to school get a job or something

Do you get tired even when you don’t get a full night sleep you think the fatigue is because you don’t sleep? I think it’s a lot on my mind, even when I sleep I still feel tired, pressure that I can’t breathe, thoughts of uncertainly am I doing the right thing am I abusing my kids am I hurting my kids.

In what ways? I mean I took them away from home and their dad from what they have known and their comfort zone.

When your mom younger did you wish your mom would have stayed? YES (seriously voice)

How do you handle those thought I mean your experiencing those things again?

Liz feels angry at herself right now if this is supposed to be life. Now she’s wondering if this is supposed to be her life.

It sounds what you have been experiencing at childhood and marriage you have a lot of opinions you carry that every day? I can’t please everyone I feel it

Eating, exercise any fresh air these last two months? If it’s a positive vie lost weight, rarely eats, no appetite, don’t feel like eating, makes kids good but makes them eat. It’s hard to take showers, she doesn’t put make up on anymore, feels no pleasure in getting ready or trying to look good.

Thoughts of hurting yourself? Anyone else? My objective is for you to be safe and built trust. She doesn’t want to be here anymore,

If you do it, how would it be? She said what if the kids were better off wouldn’t disappoint mom if she wasn’t here, right now she feels like she’s hurting people she loves.

What about you hurting yourself, will you keep yourself safe? How often are the thoughts of hurting yourself? I loved to be happy could love for things to be perfect but don’t know how to fix it. I don’t know how.

This is an important step you made an appointment and showed up today. This shows you have hope because you’re here start to feel the hopeful and build on it. Means possibility to feel better. It takes a lot of courage. You being here tells me there’s hope possibility that you can feel better and you will find the answers that you’re needing.

I’m concern that you’re coming down pretty hard on yourself with yourself and sounds that Robert caused the pain and you’re trying to heal it. Robert is a good man deep inside wish I could help him change.

Did your mom change your father? I don’t know I was little girl. I tried to he smiled laughed and play full. I thought he was happy then he would pick fights with mom full blown fights next time you know she was his punching bag. (Sad)

It feels like when you were a little girl you were afraid and weak? I never thought about it.

What was it about your sister to move to Washington why do you think she did that? My sister moved to Washington because she had a bigger better dreams. Always said she wanted to explore the world she didn’t want to be like mom.

What is her relationship with her and your mother? Pretty good relationship with mom, Mom likes to talk trash because her sister is not around not available.

Sister calls and tells her she loves her, checks in to see if she’s ok and if she needs anything. She supports her to move forward.

Both her sister and Karen her friend want her to live a different life. Don’t know is she has the energy and the confidence.

Tell me about a time when you had energy and confidence? I was much younger 18 or 19 years old more energy and confidence. (She nods yes) Hasn’t thought of younger self till now. (Smiles and holds back tears)

Do you ever go out with Karen? Yes for lunch we hang out of course I have no money so they cook at her mom’s. Burritos you know or chorizo, (she smiles) When she’s around Karen she feels good she smiles and she’s a good friend. (Calm secure about what she said)

What’s your mood day to day give me a family history are you smoking cigarettes are you using any substance any careen to help you cope? I suppose I probably would take up drinking or smoking but I can’t afford anything don’t smoke or drink only drink coffee to stay awake during the day doesn’t help. Always tired confused during the day and night can’t sleep.

Any history of substance abuse in family or marriage with Robert alcohol or drugs? Robert Drinks on weekend gradually became a problem drank during the week she was ok with him drinking only drinking on the weekends and going out. Slowly started to drink all the days of the week sometimes he wouldn’t get up to go to work on time. Call him out he gets angry.

Every any relationship between the abuse and drinking? Yes he thought it was ok, He would yell at her even for the smallest things telling her she was worthless, wouldn’t amount to anything, she couldn’t make it on her own, she would never leave him.

Sorry to hear that. Anyone in the family with substance abuse? My dad was a drinker. They knew when dad drank it would probably turn out into a fight with her mother. Liz felt angry with her mother because she never left her father. Right now she doesn’t want her kids to feel the same way any with her either.

This is understandable for all this to be a conflict. Like I said there’s a lot of hope and we will build upon this. We will proceed with our next appointment. (End of movie) no age was given looks to be in mid 30’s, no education level was given only that she would go back to school.