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Application: Time-Limited Dynamic Psychotherapy—Case Conceptualization

The field of psychotherapy is moving in a direction where short-or brief-term therapies are in high demand. The reasons for this shift in therapeutic "time" perspective include, to name a few, the evolution and revision of theory that allows the shortening of the typical therapeutic time frame, pressure from managed care organizations to shorten the number of covered psychotherapy sessions, and the adaptation of psychodynamic theory to environments beyond private practice or psychoanalysis. This week, you examine time-limited dynamic psychotherapy (TLDP), a short-term psychodynamic therapy considered more medium-term length than other therapeutic approaches espousing a "short-term" focus. In this Application Assignment, you evaluate Case Study: Sam through the lens of time-limited dynamic psychotherapy. Developing a comprehensive case conceptualization is a challenging exercise that requires you to integrate what you know about the client with what you understand about a theory and apply that information to a working treatment plan. This process requires you to develop a preliminary diagnosis and to evaluate the unique contextual considerations each client brings to treatment, in this instance, Sam, from this week's case study. Because case conceptualization is such a complex process, a Case Conceptualization Exemplar is provided as a guide.

To prepare for this assignment:

· Review the "Psychodynamic Approaches" sections on the DVD, Counseling: Theories in Action. Pay particular attention to the methods used by the therapists to gather information related to their clients' presenting issues. Discern some of the basic techniques associated with psychodynamic and brief therapies.

· Review Dr. Norcross' course media presentation "Psychodynamic Orientation Foundations". Pay particular attention to his discussion on short or brief psychodynamic therapies.

· Review Case Study: Sam and begin to develop a preliminary diagnosis of Sam's presenting problems.

· Download and familiarize yourself with the Case Conceptualization Exemplar and the Case Conceptualization Template .

· Review this week's assigned articles on short-term psychodynamic theories, and think about conceptualizing Case Study: Sam from a short-term psychodynamic perspective, specifically time-limited dynamic psychotherapy (TLDP).

· Review, if necessary, Chapters 1, 2, and 3 in Clinical Process: From Conceptualization to Treatment Planning. Think about how you can use the information from these chapters when you conceptualize Case Study: Sam.

· Consider the benefits and challenges of using a short-term psychodynamic therapy. Think about how you would address the challenges.

· Consult the DSM-5 and review Case Study: Sam. Formulate a preliminary diagnosis for Sam's presenting issues.

· Review this week's Web sites for empirically supported treatments appropriate for your diagnosis of Sam's presenting issues. (The ESTs should also support TLDP.)

The assignment: (The completed template should be 2-3 pages)

· Complete the Case Conceptualization Template for Case Study: Sam through the lens of time-limited dynamic psychotherapy. Practice your evidence-based practice skills by using empirically supported treatments.

Psychotherapy Interventions II

Case Studies: Alex, Sam, and Mary

Alex is a 32-year-old Caucasian female who presents to psychotherapy due to repeated “failures” (as she described them) in relationships. She describes herself as “losing herself” in relationships and “giving them her all” so that when they are over, she feels very abandoned, anxious, depressed, and empty. She reports that she is never the one who breaks up with others; she is always the one who is “dumped.” She admits that she can be emotionally intense and that she secretly wonders if she scares people off, but at the same time, she believes that love should be “all consuming.” Alex has a history of substance abuse, primarily cocaine, and usually at parties. She also admits that when not in a relationship, she seeks numerous sexual partners and doesn’t always practice safe sex. She, also, after telling you that you are the best and most understanding therapist she has ever met (and she has had five therapists in the last three years), shows you some superficial cuts on the upper part of her left arm and you observe some significant scarring indicating that this is not the first time she has injured herself.

Sam is a 42-year-old Asian male who owns a real estate business; he comes to therapy because of repeated episodes of heart palpitations. He has been in the emergency room three times this month alone and doctors have suggested that he has an emotional or mental issue rather than a physical one as they can find nothing indicating heart disease. Sam reports that his business is suffering and he fears that his marriage is heading toward divorce due to financial stress. He tells you that he has episodes in which his heart races, he feels like he is “in a movie or not real,” he sweats profusely and feels nauseated, and he honestly believes at the time that he is having a heart attack. Sam said that the episodes come “out of the blue” and that he is so fearful of having another one in public that he has started staying home more, which is further disrupting his business and straining his marriage. Sam takes no medication and has no history of substance abuse.

Mary comes to your office stating that she is feeling very sad and lonely. She tells you that she just doesn’t have energy anymore and that she has lost interest in spending time with friends and family, her job, which she used to find very rewarding, and her hobby of scrapbooking, which used to occupy most of her free time. She reports that she lies on the couch most of the day when she is not at work and flips through TV channels. Mary states that while at work, she is absentmindedly surfing the Web rather than completing job tasks. When you ask about her memory and ability to concentrate, Mary admits that she has a hard time focusing on what to do each day and she rarely completes tasks she starts. Mary is worried that she is going to lose her job because of the way she is feeling. She also reports that she wakes up early in the morning and can’t get back to sleep, and that she cries for long periods, often with no warning. Mary discloses that she was divorced six months ago, and that things have become progressively worse for her emotionally since that event. She also admits that she has lost about 25 lbs. and that she just doesn’t seem to taste food anymore.

Student Name: Case Name/#: Case Study Exemplar: Linda

1. Problem identification and definition: [1–2 paragraphs]

[Primary and contributing concerns for the client]

· Client concerns: Cognitive abilities

· Client concerns: Feeling “anxious,” associated with being accepted by others

· Clinical concerns: Interpersonal isolation

· Clinical concerns: Self-devaluation, adequacy

· Clinical concerns: Depressive symptoms

2. Contextual considerations: [1–2 paragraphs]

[What ethical, legal, cultural, or other key considerations need to be considered with this client when creating a treatment plan?]

· Given no family, friends, or beliefs were identified as a support base, it would seem there are no resources on which Linda might rely.

· Given her sustained employment, attempts at effecting change, and self-referral, it seems as Linda may have the capacity for insight, ability to sustain, and motivation for change.

3. Diagnosis

Axis I: [Be sure to provide full title and code]

300.04 Dysthymic Disorder

Axis II:

V71.09 No diagnosis on Axis II

Axis III:

None

Axis IV:

Reoccurring headaches within last 6 months

AXIS V: GAF =

45–55 Severe symptoms of impaired social and interpersonal relationships

Moderate symptoms of flat affect

Diagnostic comments: [1 paragraph]

[Provide a brief comment (no more than 1 paragraph) on the justification for your diagnosis]

1) Disturbance of mood: Exaggerated feelings of self-depreciation, self-doubt, lack of energy, problems with sleep, “headaches,” impaired decision making.

2) Dysthymic Disorder: Prolonged duration of “low self-esteem,” “feeling of hopelessness,” “depressed mood, most of day.”

4. Theoretical conceptualization: [1–2 paragraphs]

[How would your selected theoretical orientation explain the primary issues for this client, and thus which interventions/treatments would be best suited for this client?]

1) Long-standing concerns of self-worth and acceptance may be rooted in unconscious wish to be nurtured.

2) Given this, the mother/child bonding and attachment may have been impaired, early impairment may have led to “stunted” personality development and associated limited defenses, blunted libidinal energy, being self-absorbed, unmet dependency.

3) Given the long-standing and deep-rooted nature of the impairment that appears to have impacted most domains of this individual’s life, major personality change would seem the most appropriate goal for this client.

4) Given the lack of external supporting relationships, the client/patient relationship may be viewed as a source of “working out” the early parent/child relationships.

A psychodynamic orientation may best meet these two issues.

5. Treatment plan

Presenting Issue #1: Questions and concerns over cognitive abilities, interpersonal relationships, and self-worth.

Strengths: Sustained employment exemplifying “reality” and ego strength. Through intermittent and unsuccessful attempts at looking outside of self for “remedies,” client may show desire and recognized need for change.

Barriers: School-academic history, birth order, “teasing” from male siblings, genetic influences, anxiety over intellectual functioning—all of which suggests early and long-standing issues resulting in a sustained personality structure.

Goals: While symptom reduction is an obvious end, to uncover unconscious motivations and to develop successful “attachment” are basic to effect their being change.

Interventions: Note: Though cognitive testing may be an obvious intervention, given the conceptualization, this would support the client’s need to look outside herself for “answers,” therefore, this option is rejected.

Modality/Duration:

Use long-term psychotherapy focusing on the psychotherapeutic relationship and exploration of self.

Three weekly 50-minute sessions for up to 2 years

Measure of Progress:

Monitor progression of therapy sessions assessing transference and “uncovering.”

Empirically Supported References:

Case Conceptualization

Student Name: Case Name / #:

6. Problem identification & definition: [1–2 paragraphs]

[Primary and contributing concerns for the client]

7. Contextual considerations: [1–2 paragraphs]

[What ethical, legal, cultural, or other key considerations need to be considered with this client when creating a treatment plan?]

8. Diagnosis

Axis I: [be sure to provide full title and code]

Axis II:

Axis III:

Axis IV:

AXIS V: GAF =

Diagnostic Comments: [1 paragraph]

[Here, provide a brief—no more than 1 paragraph—comment on the justification for your diagnosis]

9. Theoretical Conceptualization: [1–2 paragraphs]

[How would your selected theoretical orientation explain the primary issues for this client, and thus which interventions / treatments would be best suited for this client?]

10. Treatment Plan

Presenting Issue #1:

Strengths:

Barriers:

Goals:

Interventions:

Modality / Duration:

Measure of Progress:

Presenting Issue #2:

Strengths:

Barriers:

Goals:

Interventions:

Modality / Duration:

Measure of Progress:

Presenting Issue #3:

Strengths:

Barriers:

Goals:

Interventions:

Modality / Duration:

Measure of Progress:

References from Empirically Supported Research