CP-TP OF CLAIRE 2
Case Presentation of Claire
Part I – Intake Information
Identifying Data
Date of initial assessment – 09/15/2023
Client’s name: Jane Smith
Age: 17
Gender: Female
Sexual Orientation: Heterosexual
Race: Caucasian
Ethnicity: Non-Hispanic
Marital Status: Single
Employment Status: Unemployed/Student
Part VI – Treatment Plan – 1-2 pages
Problems
1. 307.59 (F50.8) Other Specified Feeding or eating disorder (Purging Disorder)
2. 305.20 (F12.10) Cannabis Use Disorder, Mild
3. 312.39 (F63.2) Trichotillomania 5 (Hair-Pulling Disorder)
4. V61.20 (Z62.820) Parent-Child Relational Problem
Goals for Change
1. Other Specified Feeding or Eating Disorder (Purging Disorder)
a. Help client achieve a better self-image through the use of (CBT).
b. Help client understand the dangerous health effects of purging and using
laxatives beyond their recommended use.
c. Work with client to help them understand and identify the connections
between maladaptive core beliefs, cognitive errors, and purging disorder.
d. Help client identify maladaptive thoughts and intrusive thoughts regarding
personal image so they can adjust accordingly so those negative thoughts and
emotions can be addressed in a healthy manner.
2. Cannabis Use Disorder
a. Have the client understand cannabis’ effects as well as the consequences that
cannabis use can have on personal goals, relationships, and overall health.
b. Learn healthy and positive coping skills to help replace the urge to use
cannabis.
c. Stop using cannabis.
2. Trichotillomania 5 (Hair-Pulling Disorder)
a. Employ Cognitive Behavioral Therapy, specifically (Habit Reversal Training)
HRT, to help the client identify other healthy outlets for the urges surrounding
CP-TP OF CLAIRE 3
their need to pull their hair, such as clenching fists.
b. Use Decoupling Method to allow the client to learn to move their hand to
another location when the urge to pull their hair arises as described by the
Mayo Clinic’s treatment for this condition.
3. Parent-Child Relational Problem
a. Work with the client, as well as client’s parents to address the; lack of
involvement in their child’s life, lack of supervision, and inadequate parental
control.
b. Help Client and Parents establish healthy boundaries, establish methods to
communicate more overtly and clearly, and teach awareness of avoidance and
passivity.
Objectives & Therapeutic Interventions
Client will engage in 12-24 weekly individual sessions with a counselor and nutritionist
to address Other Specified Feeding or Eating Disorder (Purging Disorder) as well as
personalized CBT to address Cannabis Use Disorder and Trichotillomania 5 (Hair-Pulling
Disorder) (Beck Institute, n.d.; Schwitzer and Rubin, 2015; Murdock, 2017). Also, the
client and parents will attend 8-12 weekly sessions to address Parent-Child Relational
Problem.
Other Specified Feeding or Eating Disorder (Purging Disorder)
Provide psychoeducation regarding maladaptive core beliefs, maladaptive
assumptions, and lack of coping strategies and CBTs conceptualization and
treatment for eating disorders.
Client will learn to identify personal low body image, poor self-esteem, and
negative self-image as well as their triggers.
Client will work on replacing negative thoughts with positive ones, as well as
reinforcing personal positive body image.
Client will adopt healthy eating habits.
oCounselor will work with client and nutritionist to help restore a normal
dietary intake as well as address negative thoughts surrounding body
weight and shape.
oCounselor will help the client establish a self-care and healthy personal
maintenance routine with healthy and positive activities.
Cannabis Use Disorder
Provide psychoeducation regarding the psychological effects of cannabis use, the
effects on personal relationships and goals, as well as overall health effects.
Client will use CBT techniques to identify triggers that lead to cannabis use and in
turn, find other outlets for those urges.
Client will use learned CBT techniques to identify poor coping strategies,
maladaptive core beliefs and assumptions.
Client will complete a daily journal to notate when urges for usage arises and
what they are doing to combat those urges.
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oCounselor will incorporate various relaxation techniques that the client
can use when urges to use cannabis arise such as; muscle relaxation,
breathing exercises, and guided imagery.
oCounselor will provide time for extra sessions either in person or via video
conferencing (virtual) to address important struggles as they come up.
Trichotillomania 5 (Hair-Pulling Disorder)
Provide psychoeducation on Trichotillomania regarding it being a body-focused
repetitive behavior (BFRB).
Client will complete weekly homework in calming techniques, cognitive
restructuring skills, and problem solving.
Client will monitor and log hair growth and pulling in their journal.
Client will log emotions and trigger they experience when a “hair pulling” urge
strikes them.
oCounselor will provide healthy alternative repetitive exercises to replace
the hair pulling during urges.
oClient will provide breathing techniques, muscle relaxation techniques, as
well as alternative exercises to employ during “hair pulling” urges.
Parent-Child Relational Problem
Provide psychoeducation regarding Parent-Child Relational Problems and
Family Dynamics.
Client will journal family interactions and the emotions that stem from those
interactions.
Client will use healthy alternative methods of communication with client’s
parents in order to establish a safe, clear, and concise dialog.
oCounselor will establish weekly sessions with client and client’s parents to
promote a healthy relationship between parents and child.
oCounselor will work with both client and client’s parents to help maintain
a balanced understanding of all parties’ perspectives and feelings.
oCounselor will provide parents with literature regarding irrational
rejection by a child, child alienation, and how to communicate with each
other in the presence of their child.
Outcome Measures of Change
Development of healthy dietary habits, as well as, improved overall self-worth, and
elimination of purging. Development of positive self-image, self-affirming attitudes towards
self, happy and enjoyable family functions, and healthy and safe coping habits.
Comparison of Pre and Post treatment measured scores on the Body Shape
Questionnaire (BSQ).
Comparison of Pre and Post treatment measured scores on the Beck Depression
Inventory (BDI).
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Client and Client’s parents reported elimination of purging behaviors.
Client reported length of hair growth as well as the elimination of hair pulling
urges.
Comparison of Pre and Post treatment measured scores on Eating Disorder
Inventory.
Counselor was contacted by Client’s school regarding Client’s improved
attendance and grades.
Counselor observed improved family dynamics, as well as client’s adapted beliefs
regarding self, school, and family relations.
References
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American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders
(5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Beck, J., & Beck, A. T. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.).
Guilford Publications.
Murdock, H. L. (2017). Theories of counseling and psychotherapy: A case approach (4th ed.).
Pearson.
Rubin, A. M., & Switzer, L. C. (2015). Diagnosis & treatment planning skills: A popular culture
casebook approach (2nd ed.). Sage.
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